(15) In Phase I of the study (qualitative phase), NCI contracted with the social marketing firm Salter>Mitchell (S>M) to conduct focus groups to test a series of potential corrective statements for use in United States v. Philip Morris USA, Inc. The objectives of this research were: to evaluate message comprehension; assess the potential for negative, unintended consequences such as boomerang effects, smoking urges, and knowledge gaps; compare potential corrective statements to determine which were the most effective; and winnow and enhance statements prior to the quantitative research phase.

(16) Eight 90-minute focus groups were conducted from November 18 through December 2, 2010, to test the corrective statements with current, never, and former smokers of low SES and average/high SES, Spanish-dominant Hispanic adults, and teens aged 14–17 (smokers and nonsmokers).

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(17) The corrective statements tested were those proposed to the Court in 2006 by Defendants BATCo, Philip Morris, RJ Reynolds, and Lorillard; modified versions of those proposed in 2006 by the Public Health Intervenors; and a new set of statements prepared by the NCI in conjunction with S>M for this research. Corrective statements were tested in all five topic areas ordered by the Court. Thirty corrective statements were evaluated, covering the five topic areas ordered by the Court, with six statements tested for each topic area. Focus group participants were unaware of the sources of the corrective statements they were asked to evaluate.

(18) Participants were asked to give feedback on corrective statements from the six different sources in all five topic areas. They were a strategic decisions.

(20) A summary of the Phase I focus group results is provided below:

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• Participants felt the Intervenors’ statements communicated messages more clearly than others and attracted their attention the most. They preferred statements that were direct and concise over statements that were long or wordy.

• While teens and Hispanics responded similarly to the general population groups, there was more variability within the teen and Hispanic groups than within the other focus groups.

• Having a corrective statement say that it was “court ordered” was widely considered a positive attribute, and gave the statement more credibility. However, virtually all respondents reacted negatively to excessive use of legal language.

• Participants in all eight focus groups generally trusted the Surgeon General as a source of information. Providing the name of a cigarette manufacturer neither added nor reduced credibility. The inclusion of such sponsor information, however, did spark some dialogue about the negative perception of cigarette manufacturers as uncaring businesses centered on sales.

• While current smokers reported that they learned new information from the corrective statements in general, they rarely said that any of the statements would make them think about quitting smoking. Nonsmokers, however, did believe the statements would have an impact on nonsmokers, perhaps to prevent individuals from starting to smoke.

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• Participants generally reported that after reading the highest-ranking statements they would be unlikely to believe opposite future claims.

EXCERPT

(21) The focus group research in Phase I was used to reduce the number of statements tested in Phase II, the Quantitative Phase, from six down to four proposed statements for each topic, based on the focus groups’ rankings and feedback on the proposed corrective statements.

(22) All ten of the statements that were dropped based on the focus-group research were proposed by the Defendants, and included all five statements proposed by BATCo. All five statements proposed by the Intervenors, by NCI, and by Philip Morris were carried forward to the Phase II quantitative testing. RJ Reynolds and Lorillard each had some proposed statements dropped and some carried forward.

(23) These are the 10 proposed statements that were dropped based on the Phase I focus-group testing:

(24) The primary aim of Phase II was to use an experimental design to evaluate the proposed corrective statements with a nationally representative sample of adults and teens on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) smoking urges and behavioral intentions around quitting smoking and staying quit in current and former smokers.

(25) The secondary aim of the quantitative phase of the study was to explore any observed, broad patterns of effect modification in order to evaluate the potential for the corrective statements to be received differentially in the population based on smoking status, income, age, or race/ethnicity given the disproportionate levels of tobacco advertising and smoking prevalence within and across populations.

(26) The survey research firm Knowledge Networks was used to field a nationally representative survey of 3,617 adults and teens from December 31, 2010 to January 10,
2011. Throughout the survey, participants were unaware of the source of the corrective statements they were asked to evaluate.

EXCERPT

I.3.iv. Summary of Recommendations to the Court, by Topic Area

(37) Accurate knowledge, attention, and perceived public impact are important markers of comprehension and should be used in considering the statements’ potential to inoculate against future misinformation. On measures of these constructs, several of the proposed statements performed significantly better than the control condition in my experimental study. I used the odds ratios on these constructs, as well as the overall statement rankings and observed potential for unintended consequences, as the primary considerations in making my recommendations. Consistency with impressions offered by focus group participants also was considered.

EXCERPT

(43) Based upon the research described in this report, the Court can be confident that the recommended corrective statements are likely to capture attention, enhance accurate knowledge, have positive public impact, and reduce the likelihood that consumers will believe potential future misrepresentations about the topics the Court identified. In addition, this study showed that the recommended corrective statements are not likely to cause negative unintended consequences in the population.

(2010), issued on August 17, 2006, ordered the Defendants to publish and disseminate court-approved corrective statements on five specific topics. The Court found that requiring the Defendants to make such corrective statements was “appropriate and necessary to prevent and restrain them from making fraudulent public statements on smoking and health matters in the future” (page 926).

(54) The Court ordered the Defendants to publish corrective statements in newspapers and disseminate them through other channels sal or by deposition.

EXCERPT

(58) I am a Federal employee with the National Cancer Institute. I have been charged with providing a foundation of evidence to aid the Court’s decision on the corrective statements to impose. I have been asked to evaluate the proposed corrective statements submitted to the Court in 2006 by the cigarette manufacturers and the Public Health Intervenors, and to develop and test a set of potential new corrective statements.

(59) Under my direction, both qualitative and quantitative techniques were utilized to evaluate the proposed corrective statements on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) behavioral intentions around quitting smoking and staying quit in current and former smokers.

(60) I also assessed how the proposed corrective statements may be differentially received and understood by several segments of the U.S. population, including youth (aged 14–17) and adults (aged 18+); English- and Spanish- dominant speakers; current, former, and never smokers; people of different races and ethnicities; and individuals of low socioeconomic status.

(61) I assessed to what extent, if any, the proposed statements may have unintended consequences such as boomerang effects (e.g., causing smoking urges or negatively affecting behavioral intentions to quit or stay quit in current and former smokers) and to what extent the proposed statements may affect how people would respond to future misrepresentations about the health consequences of smoking. . . .

EXCERPT

IV. MATERIALS CONSIDERED

(65) In forming my opinion, I relied on materials provided to me by counsel or gathered by me or at my direction, including existing published research in my field of study and studies involving corrective statement evaluations. Documents that I have considered in forming my expert opinion and preparing this report are listed in Appendix B.

EXCERPT

(77) In Phase I, NCI contracted with the social marketing firm Salter>Mitchell (S>M) to conduct focus groups to test a series of potential corrective statements for use in United States v. Philip Morris USA, Inc.

(78) Focus groups are a form of qualitative research that utilizes group interactions to assess how and why people think a certain covered in the allotted time for the focus groups.

(88) The sources of the corrective statements tested in Phase I are as shown below. The first five sets were submitted to the Court in 2006. The sixth was prepared by the National Cancer Institute in conjunction with S>M for this project, and is referred to as the “NCI statement” or “NCI.”

(178) Across nearly all topic areas and key outcome variables, the statements proposed by the Intervenors and the National Cancer Institute generally performed better than those proposed by the tobacco industry, both when compared to the control condition, and when ranked against all proposed statements under study. This pattern was particularly evident on outcome variables seen as highly relevant to this evaluation—accurate knowledge, attention, and potential for public impact.

(179) The exploratory analysis of potential different particular statement was consistently received differentially by some population groups compared to others. I believe that the main effects models are the most robust, and provide the most insight into the proposed statements’ performance.

(180) Results detailed below, by topic area, will not discuss how individual proposed corrective statements performed on the measure of confusion (“How confusing, if at all, would you say that this statement was for you to understand?”). This is because higher levels of confusion were widely reported across all topic areas for nearly all proposed corrective statements than for the control condition (a Surgeon General’s warning). This finding is not surprising given that all the proposed corrective statements contain more detailed information than the Surgeon General’s warning and, given the wide dissemination of the Surgeon General’s warning, the likely familiarity of the text for many individuals in the study. These results are not seen as indicating a problem related to the comprehension of the proposed statements, especially because in bivariate analyses, nearly all statements in all topic areas had majority agreement that they were “not at all confusing.”

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(181) Our measures of triggering smoking urges in current and former smokers indicated only two significant results across all topic areas and statements; specifically, the Intervenors’ and NCI secondhand smoke statements were positively associated with triggering smoking urges in current and former smokers. Despite these two instances, I do not report major concerns regarding the corrective statements’ potential to cause smoking cravings among current and former smokers.

EXCERPT

(222) Data gathered from eight focus groups (N=62) and a nationally representative survey (N=3,617) of adults and teens reveals that the proposed corrective statements remedy has strong potential to increase knowledge in the population, particularly in areas where there has been a dearth of information available in the public information environment.

(223) Accurate knowledge, attention, and perceived public impact are important markers of comprehension and should be used in considering the statements’ potential to “inoculate” people against future misinformation. On measures of these constructs, several of the proposed statements performed significantly better than the control condition in the experimental study. I used the odds ratios on those constructs, as well as the overall statement rankings and observed potential for unintended consequences, as the primary considerations in making my recommendations. Consistency with impressions offered by focus group participants also was considered.

(224) Our data do not point to any serious concerns with negative unintended consequences related to the corrective statements that were tested. I saw no broad patterns of effect modification; none of the statements consistently performed poorly on measures of accurate knowledge, attention, and credibility with teens compared to adults, low SES individuals versus higher SES people, current versus never and former smokers, or individuals who are African American, Spanish-dominant Hispanic, or other race compared to Whites. Nonetheless, decades of research on mass communication efforts indicates that, due to social disparities in health information access, usage, and comprehension, there is always the potential for deficits in accurate knowledge to occur in vulnerable populations. This will be an important area to monitor as the corrective statements remedy is implemented at the population level.

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(225) Current and former smokers who saw the NCI and Intervenors’ statements in the secondhand smoke topic area were more likely to report smoking urges after exposure to those statements compared to current and former smokers who saw the control condition. My recommendations take this unintended consequence into consideration.

(226) Similarly, the data reveal that in the topic area related to the addictiveness of smoking and nicotine, the Lorillard and Philip Morris statements were negatively associated with quit intentions among smokers compared to the quit intentions of smokers who saw the control condition. These findings also were taken into account in my recommendations.

V.5. Recommendations to the Court

Topic A: Negative Health Effects of Smoking

• Recommendation: National Cancer Institute

(227) While the NCI, Intervenors, and Philip Morris negative health effects statements all performed statistically better than the control condition on measures of attention and potential for public impact, the NCI statement was the only statement that performed statistically better than control on increasing accurate knowledge. It was also positively associated with behavioral intentions to stay quit among former smokers, and had the second highest global ranking in this topic area.

Topic B: Addictiveness of Smoking and Nicotine

• Recommendation: Intervenors

(228) The proposed statements from the Intervenors and NCI were significantly stronger than control on garnering attention in the topic area of addictiveness of smoking and nicotine.

The Intervenors’ statement had the second highest global ranking when respondents saw and rated all statements in this topic area, and was positively associated with behavioral intentions to stay quit among former smokers. In contrast, the Lorillard and Philip Morris statements were negatively associated with quit intentions among smokers, and they were also significantly less likely to have perceived potential for public impact. None of the proposed statements performed statistically better than control on increasing accurate knowledge.

(229) Making a recommendation for the low tar statements required a slightly more complex analysis. None of the proposed corrective statements produced unintended consequences, and nearly all the statements performed better than the control condition on measures of attention, potential for public impact, and credibility. The Philip Morris statement was the only statement to be positively associated with increasing accurate knowledge compared to control, but it ranked third among all the statements on the global rankings. The Intervenors’ and NCI statements ranked #1 and #2, respectively, on the global rankings.

While the Intervenors, NCI, or Philip Morris statements would be acceptable based on these data alone, the Intervenors’ statement proved stronger in two additional areas. First, in looking for broad patterns of effect modification, the data reveal that only the Intervenors’ statement had the potential to increase knowledge in current smokers and in low income populations, which are important populations for this particular topic area.

Further, in the qualitative phase of the study, the Intervenors’ statement far outranked both the NCI and Philip Morris statements.

(230) The statements proposed by NCI and the Intervenors performed equally well on constructs of interest and global rankings (#1 and #2, respectively). Both were significantly better than control on their perceived potential to have public impact, and they were both positively associated with increasing accurate knowledge, as was the RJ Reynolds statement. The Intervenors’ statement, however, far outranked the NCI statement among focus group participants, and was particularly well-received in the Spanish-language and teen focus groups. Both the Philip Morris and RJ Reynolds statements were negatively associated with trust compared to control. None of the statements in this category produced notable unintended consequences.

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Topic E: Adverse Health Effects of Secondhand Smoke

• Recommendation: RJ Reynolds

(231) Nearly all statements in the secondhand smoke topic area performed statistically better than control on measures of knowledge, attention, potential for public impact, and credibility. Despite being ranked #1 and #2, respectively, in the global rankings, the Intervenors’ and NCI statements were positively associated with triggering smoking urges after exposure compared to current and former smokers who saw the control condition. The RJ Reynolds statement ranked #3 in the global rankings and focus groups, but—unlike the Intervenors’ and NCI statements—was not associated with any unintended consequences, and performed as well as the other statements on constructs of interest when compared to the control condition.

(232) As such, the RJ Reynolds statement is the conservative choice for the secondhand smoke topic area. The Court might consider, however, that in this particular topic area, my findings related to smoking urges could be interpreted differently. It is possible that the Intervenors’ and NCI statements communicated the harms associated with secondhand smoke more clearly and were therefore more impactful, thus causing an indirect evocation of smoking urges due to eliciting an emotion such as anxiety. It is beyond the scope of the collected data to explore this possibility in a meaningful way.

Source Attribution and Sponsorship

(233) Based on my research, I identified one introductory source attribution statement and one sponsorship notice as performing better than the others. However, the research data that is currently available would not yet support the Court’s substituting these better-performing introductory and concluding sentences across all of the five statements I am recommending. There are two reasons for this. The first is that the better-performing sponsorship notice references the 2004 Surgeon General’s Report; that source does provide information about the negative health effects of smoking, but it would be inaccurate to cite it as the source for all five topics.

(234) The second is that substituting a different introductory source attribution statement or sponsorship notice to a particular message has the potential to change the frame of the

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message for some people. Further study, using focus groups, would help to ensure that adjusting the introductory and concluding sentences would not change comprehension or attitudes towards the message in a substantive way.

(235) My analysis of the introductory source attribution statements was done out of the context of the corrective statements themselves. This was done in order to objectively evaluate the proposed introductory source attribution statements. With the exception of introductory statement 1 (“The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in…”), all the introductory statements rated relatively well on attention and trust and can be considered acceptable. Introductory statement 2 received the highest global rankings for attention and trust, followed by introductory statement 5. Therefore, introductory statement 2 is the most appropriate choice for source attribution. My recommendation, however, is that for each topic area, the recommended corrective statements remain intact for implementation, unless further focus group research can be conducted to confirm that changing the introductory sentences would not change the overall effect of the corrective statements on target populations.

• Best-Performing: Sponsorship Notice 2 (“This message is furnished by [Cigarette Company Name] pursuant to a court order and is taken from the 2004 Surgeon General’s Report.”)

(236) My analysis of the sponsorship notices was done out of the context of the corrective statements themselves, in order to objectively evaluate different sponsorship notices. All the sponsorship notices rated relatively well on trust and can be considered acceptable. While sponsorship notices 2 and 3 had near even global rankings on trust, current smokers ranked sponsorship notice 3 (“These conclusions are contained in the 1988 Surgeon General’s report. [Cigarette Manufacturer Name] encourages…”) lower. Therefore, sponsorship notice 2 is the best performing.

(237) My recommendation, however, is that for each topic area, the recommended corrective statements remain intact for implementation, unless further focus group research can be

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conducted to confirm that changing the sponsorship notice would not change the overall effect of the corrective statements on target populations. With the exception of the negative health effects corrective statement, each of the corrective statements I recommend contains a sponsorship notice approximating that ordered by the Court.

(238) Sponsorship notice 2 references the 2004 Surgeon General’s Report, which is appropriate for corrective statements under Topic A: Negative Health Effects. Should the Court choose to recommend that sponsorship notice 2 be required as part of the corrective statements remedy, the date of the Surgeon General’s Report will need to be modified based on the topic area to which it is attached. I am not aware of a Surgeon General’s Report that addresses cigarette design manipulation, so for Topic D, the sponsorship notice would need to be modified.

EXCERPT

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VI. CONCLUSION

(247) This report has described an evaluation of the proposed corrective statements based on a well-established formative research process that is broadly used within the field of health communication science. Based upon the research described in this report, the Court can feel confident that the recommended corrective statements are likely to capture attention, enhance accurate knowledge, have a positive impact on the public, and reduce the likelihood that consumers will believe potential future misrepresentations about the topics the Court identified. In addition, the study showed that the recommended corrective statements are not likely to cause negative, unintended consequences in the population. I hope that the recommendations prove helpful in the issuance of corrective statements for implementation.

(1) As part of the Court’s Final Order in United States v. Philip Morris USA, Inc., 449 F. Supp. 2d 1 (D.D.C. 2006), aff’d in part & vacated in part, 566 F.3d 1095 (D.C. Cir. 2009) (per curiam), cert. denied, 561 U.S. ___, 130 S. Ct. 3501 (2010), issued on August 17, 2006, the Court ordered the Defendants to publish and disseminate court-approved corrective statements on five specific topics. The Court found that ordering the Defendants to make such corrective statements was “appropriate and necessary to prevent and restrain them from making fraudulent public statements on smoking and health matters in the future” (page 926).

(2) Court-approved corrective statements were ordered to be published by the Defendants in newspapers and be disseminated through other channels such as television, cigarette package onserts, retail displays, advertisements, and on the Defendants’ corporate Web sites. The corrective statements were ordered to address:

d. the Defendants’ manipulation of cigarette design and composition to ensure optimum nicotine delivery; and

e. the adverse health effects of exposure to secondhand smoke (also known as environmental tobacco smoke or ETS).

I.2. Background

(3) I have been charged by the Department of Justice, as a Federal employee with the National Cancer Institute (NCI), under the National Institutes of Health (NIH) and U.S.

Department of Health and Human Services (HHS). As part of this task, I have been

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asked to provide a foundation of evidence to aid the Court’s decision on what corrective statements to impose. I have been asked to evaluate the proposed corrective statements submitted to the Court in 2006 by the cigarette manufacturers and the Public Health Intervenors, and to develop and test a set of potential new corrective statements.

(4) Any corrective statements would be made in the context of what the Court determined was the Defendants’ 50-year history of misrepresenting the health consequences of smoking cigarettes. It is my intention that this report provide a scientific foundation of evidence to aid the Court in issuing the most effective corrective statements, and those with the least potential to have negative unintended consequences.

(5) While working on this matter, I was assisted by a staff of tobacco control and communication scientists and statisticians from NCI, in addition to staff and researchers from the social marketing firm Salter>Mitchell and the survey research firm Knowledge Networks. I was also assisted by administrative and scientific staff from Information Management Systems and BLH Technologies, Inc. Additionally, over the course of my research, I consulted occasionally with staff members at the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC).

I.3. Summary of NCI Corrective Statements Study

I.3.i. Overview

(6) Media exposure is associated with health attitudes, knowledge, and behavior, and accurate knowledge has been a central component of effective health promotion in several areas.

(7) Knowledge of the risks associated with tobacco use is not evenly distributed in the population. In particular, individuals with low socioeconomic status (SES) (using income, education, and occupation as markers of SES) are significantly more likely to believe myths about smoking and hold inaccurate beliefs about the risks of smoking.

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(8) Despite the success of several large-scale public health campaigns, there is evidence that some public health campaigns, including those with mass media components, have had ambiguous or no effects (e.g., the Stanford Five City Program and the COMMIT project).

Moreover, there is evidence that some public health campaigns have resulted in unintended consequences such as boomerang effects and knowledge gaps.

ii. The Knowledge Gap Hypothesis documents a long-held observation that absent some conditions, the flow of information on a given topic can lead to differential learning among members of certain population groups, delineated by SES, race and ethnicity, and geographic area. A related concept, communication inequality, posits that differences in the way health information is created and distributed among and across groups can create knowledge gaps among those that do and do not receive adequate exposure to health information.

(9) These unintended consequences underscore the need to carefully pre-test messages, plan for their dissemination, and conduct process evaluation. Message testing is the single best method to guard against counterproductive features of health communication endeavors that may produce undesired responses.

(10) The study described in this report aimed to evaluate the proposed corrective statements submitted to the Court in 2006 by the cigarette manufacturers and the Public Health Intervenors, and to develop and evaluate potential new corrective statements.

(11) Under my direction, qualitative and quantitative techniques were utilized to evaluate the proposed corrective statements on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) behavioral intentions around quitting smoking and staying quit in current and former smokers.

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(12) I also assessed how the proposed corrective statements may be differentially received and understood by several segments of the U.S. population, including youth (aged 14–17) and adults (aged 18+); English- and Spanish- dominant speakers; current, former, and never smokers; people of different races and ethnicities; and individuals of low socioeconomic status.

(13) I assessed to what extent, if any, the proposed statements may have unintended consequences such as boomerang effects (e.g., causing smoking urges or negatively affecting behavioral intentions to quit or stay quit in current and former smokers) and to what extent the proposed statements may affect how people would respond to future misrepresentations about the health consequences of smoking.

(14) Recommendations are based on data from adults and teens who participated in eight focus groups (N=62) and a nationally representative survey (N=3,617). To my knowledge, this is the most comprehensive research effort to date to evaluate the corrective statements remedy issued as part of United States v. Philip Morris USA, Inc.

I.3.ii. Phase I: Qualitative Evaluation

(15) In Phase I of the study (qualitative phase), NCI contracted with the social marketing firm Salter>Mitchell (S>M) to conduct focus groups to test a series of potential corrective statements for use in United States v. Philip Morris USA, Inc. The objectives of this research were: to evaluate message comprehension; assess the potential for negative, unintended consequences such as boomerang effects, smoking urges, and knowledge gaps; compare potential corrective statements to determine which were the most effective; and winnow and enhance statements prior to the quantitative research phase.

(16) Eight 90-minute focus groups were conducted from November 18 through December 2, 2010, to test the corrective statements with current, never, and former smokers of low SES and average/high SES, Spanish-dominant Hispanic adults, and teens aged 14–17 (smokers and nonsmokers).

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(17) The corrective statements tested were those proposed to the Court in 2006 by Defendants BATCo, Philip Morris, RJ Reynolds, and Lorillard; modified versions of those proposed in 2006 by the Public Health Intervenors; and a new set of statements prepared by the NCI in conjunction with S>M for this research. Corrective statements were tested in all five topic areas ordered by the Court. Thirty corrective statements were evaluated, covering the five topic areas ordered by the Court, with six statements tested for each topic area. Focus group participants were unaware of the sources of the corrective statements they were asked to evaluate.

(18) Participants were asked to give feedback on corrective statements from the six different sources in all five topic areas. They were asked to read and identify the main idea of each potential corrective statement, and then to rank the statements within each topic area according to how clearly each communicated the corrective area topic, how well it caught their attention, and how much it would impact them personally. After participants described the reasons for their rankings, the focus groups then discussed the highestranked statements’ likely impact on smoking perceptions and behaviors; any confusing language; believability; any new information; and potential impact on believing future “opposite claims.” Finally, participants were asked to discuss the impact of the introductory text in some of the statements, expressly saying they were being issued as a result of a court order; and the impact of text in some of the statements, saying they were being sponsored by a particular cigarette manufacturer.

(19) It is important to note that qualitative research is exploratory in nature and not intended to provide data that are quantifiable or “projectable” to a stated population. Rather, it is typically used to elicit reactions and ideas from participants about a particular topic in order to generate insights that can inform strategic decisions.

(20) A summary of the Phase I focus group results is provided below:

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• Participants felt the Intervenors’ statements communicated messages more clearly than others and attracted their attention the most. They preferred statements that were direct and concise over statements that were long or wordy.

• While teens and Hispanics responded similarly to the general population groups, there was more variability within the teen and Hispanic groups than within the other focus groups.

• Participants used words like “scare tactics” to describe some of the cigarettemanufacturers’ proposed statements that included long lists of diseases and conditions.

• Participants generally made a distinction between lists of health hazards (diseases) and statistics about deaths. They viewed lists of diseases as messages they are already used to seeing, while statistics about deaths seemed to strike participants more as facts rather than possibilities. Many participants felt that statements that avoided excessive medical language were easier to understand.

• Most participants commented on the “shocking” nature of some of the information in the statements, particularly of those citing the adverse health effects of smoking on the individual and adverse effects of secondhand smoke on the health of the fetus and on children.

• Having a corrective statement say that it was “court ordered” was widely considered a positive attribute, and gave the statement more credibility. However, virtually all respondents reacted negatively to excessive use of legal language.

• Participants in all eight focus groups generally trusted the Surgeon General as a source of information. Providing the name of a cigarette manufacturer neither added nor reduced credibility. The inclusion of such sponsor information, however, did spark some dialogue about the negative perception of cigarette manufacturers as uncaring businesses centered on sales.

• While current smokers reported that they learned new information from the corrective statements in general, they rarely said that any of the statements would make them think about quitting smoking. Nonsmokers, however, did believe the statements would have an impact on nonsmokers, perhaps to prevent individuals from starting to smoke.

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• Participants generally reported that after reading the highest-ranking statements they would be unlikely to believe opposite future claims.

• Participants in the teen focus groups generally understood all the terms in the statements. Some admitted they would ignore these statements because they were long and detailed.

(21) The focus group research in Phase I was used to reduce the number of statements tested in Phase II, the Quantitative Phase, from six down to four proposed statements for each topic, based on the focus groups’ rankings and feedback on the proposed corrective statements.

(22) All ten of the statements that were dropped based on the focus-group research were proposed by the Defendants, and included all five statements proposed by BATCo. All five statements proposed by the Intervenors, by NCI, and by Philip Morris were carried forward to the Phase II quantitative testing. RJ Reynolds and Lorillard each had some proposed statements dropped and some carried forward.

(23) These are the 10 proposed statements that were dropped based on the Phase I focus-group testing:

(24) The primary aim of Phase II was to use an experimental design to evaluate the proposed corrective statements with a nationally representative sample of adults and teens on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) smoking urges and behavioral intentions around quitting smoking and staying quit in current and former smokers.

(25) The secondary aim of the quantitative phase of the study was to explore any observed, broad patterns of effect modification in order to evaluate the potential for the corrective statements to be received differentially in the population based on smoking status, income, age, or race/ethnicity given the disproportionate levels of tobacco advertising and smoking prevalence within and across populations.

(26) The survey research firm Knowledge Networks was used to field a nationally representative survey of 3,617 adults and teens from December 31, 2010 to January 10,
2011. Throughout the survey, participants were unaware of the source of the corrective statements they were asked to evaluate.

(27) The target population for the survey consisted of:

• Current smokers above the 200% Federal poverty level, aged 18 and over

• Current smokers at or below the 200% Federal poverty level, aged 18 and over

• Former smokers and never smokers above the 200% Federal poverty level, aged 18 and over

• Former smokers and never smokers at or below the 200% Federal poverty level, aged 18 and over

• African Americans, aged 18 and over

• Predominantly Spanish speaking Hispanics, aged 18 and over

• Teenagers aged 14 to 17 years

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(28) I first calculated weighted percentages for statement rankings within five topic areas under study: Topic A: The adverse health effects of smoking; Topic B: The addictiveness of smoking and nicotine; Topic C: The lack of any significant health benefit from smoking “low tar,” “light,” “ultra light,” “mild,” and “natural” cigarettes; Topic D: The manipulation of cigarette design and composition to ensure optimum nicotine delivery; and Topic E:The adverse health effects of exposure to secondhand smoke (also known as environmental tobacco smoke or ETS).

(29) I then calculated bivariate estimates (cross-tabulation with Chi Square) to evaluate associations between exposure to corrective statements and all outcome variables under study, and multivariable logistic regression models to estimate the probability that exposure to specific corrective statements was associated with items assessing constructs of interest (e.g., knowledge, attention, confusion, trust, smoking urges, etc.), compared to control. All multivariable models controlled for income, education, gender, age, race/ethnicity, and baseline assessments of knowledge, behavioral intentions, last cigarette smoked (i.e., when the survey participant last smoked a cigarette [where appropriate]), and smoking status. To assess smoking urges and behavioral intentions, multivariable logistic regression models were stratified by smoking status and adjusted for the other covariates listed above.

(30) To explore potential broad patterns of effect modification in the areas of knowledge, attention, and credibility, I added interaction terms to three of the main effects models, and modeled separately the interaction between statement and smoking status, statement and income, statement and age, and statement and race/ethnicity.

(31) To assess the impact of the corrective statements on future beliefs, I calculated weighted percentages by statement for respondents reporting that, after being shown a particular proposed statement, they would believe it if they later heard the opposite claim. Similarly, I asked respondents, after showing them a particular proposed statement, whether they would believe it if they later heard that the corrective statement topic had not been proven.

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(32) To evaluate the impact that source attribution and sponsorship information might have on attention and trust, independent of the corrective statements, I calculated weighted percentages of respondents reporting that they agreed or strongly agreed that the proposed introductory source attribution statements or sponsorship notices would affect their trust or attention. To evaluate predictors of attention and trust, I used multivariable logistic regression to model the probability that attention and trust were associated with smoking status and sociodemographic characteristics of respondents.

(33) Across nearly all topic areas and key outcome variables, the statements proposed by the Intervenors and the National Cancer Institute generally performed better than those proposed by the tobacco industry when compared to the control condition and when ranked against all statements under study. This pattern was particularly evident on outcome variables seen as highly relevant to this evaluation—accurate knowledge, attention, and potential for public impact.

(34) In my exploratory analysis for potential differential effects on knowledge, attention, and credibility by target populations, I saw no broad patterns of effect modification by smoking status, income, age, or race/ethnicity.

(35) On the measures of triggering smoking urges in current and former smokers, I saw two significant results across all topic areas and statements. In the topic of secondhand smoke, the statements by the Intervenors and NCI were positively associated with smoking urges in current and former smokers.

(36) On the measures of behavioral intentions, the statements by both Philip Morris and Lorillard related to the topic of addictiveness of smoking and nicotine were significantly associated with decreased intentions to quit among current smokers. In the topic area of negative health effects, the NCI statement was positively associated with intention to stay quit among former smokers.

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I.3.iv. Summary of Recommendations to the Court, by Topic Area

(37) Accurate knowledge, attention, and perceived public impact are important markers of comprehension and should be used in considering the statements’ potential to inoculate against future misinformation. On measures of these constructs, several of the proposed statements performed significantly better than the control condition in my experimental study. I used the odds ratios on these constructs, as well as the overall statement rankings and observed potential for unintended consequences, as the primary considerations in making my recommendations. Consistency with impressions offered by focus group participants also was considered.

(38) For Topic A: Negative Health Effects of Smoking, the statement proposed by the National Cancer Institute is recommended. The statement is provided below:

Paid for by [Cigarette Manufacturer Name] under order of a Federal District Court.”

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(41) For Topic D: Defendants’ Manipulation of Cigarette Design and Composition to Ensure Optimum Nicotine Delivery, the statement proposed by the Intervenors is recommended.

The statement is provided below:

“For decades, we denied that we controlled the level of nicotine delivered in cigarettes.

Here’s the truth:

o Cigarettes are a finely-tuned nicotine delivery device designed to addict people.

o We control nicotine delivery to create and sustain smokers’ addiction, because that’s how we keep customers coming back.

o We also add chemicals, such as ammonia, to enhance the impact of nicotine and make cigarettes taste less harsh.

o When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District Court.”

(42) For Topic E: Secondhand Smoke, the statement proposed by RJ Reynolds is recommended. The statement is provided below:

“The Surgeon General has concluded:

o Exposure to environmental tobacco smoke has been proven to cause premature death and disease in children and in adults who do not smoke.

Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is taken from the 2006 Surgeon General’s Report. You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.”

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(43) Based upon the research described in this report, the Court can be confident that the recommended corrective statements are likely to capture attention, enhance accurate knowledge, have positive public impact, and reduce the likelihood that consumers will believe potential future misrepresentations about the topics the Court identified. In addition, this study showed that the recommended corrective statements are not likely to cause negative unintended consequences in the population.

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II. QUALIFICATIONS

(44) I am a Health Scientist in the Health Communication and Informatics Research Branch within the Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health. See Appendix A for my curriculum vitae.

(45) My educational background includes a doctoral degree in social epidemiology from the Harvard School of Public Health’s Department of Society, Human Development, and Health; a master’s degree in health education from the West Virginia University School of Medicine; and a bachelor’s degree in journalism and mass communication from the Marshall University School of Journalism and Mass Communication.

(46) My primary research focus is on evaluating how media exposure affects health behavior and attitudes toward public health policy. I also examine social determinants of health, primarily focusing on how communication inequalities and knowledge gaps may exacerbate health disparities among disadvantaged populations.

(47) Many of my investigations have used nationally representative surveys for data collection and analysis. I was trained under renowned experts in survey research methodology at the Harvard Opinion Research Center and with health communication scientists in Dr. K. Viswanath’s communication research lab at the Dana-Farber Cancer Institute and Harvard School of Public Health. Further, I am a member of the management team for NCI’s Health Information National Trends Survey (HINTS), which collects nationally representative data about the American public’s use of health information.

(48) In addition to my facility with survey research, my professional experience over the past 15 years has included working with research teams to conduct focus groups and in-depth interviews to formulate and evaluate a variety of public health messages and intervention strategies with various audience segments (e.g., blue-collar workers, low socioeconomic status individuals, community health workers, targeted racial/ethnic groups, and smokers). In addition, I have led several usability testing studies for a variety of organizations and health intervention-oriented Web sites.

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(49) Particularly relevant to this case is my research examining the effects of tobacco-specific media exposure (such as pro-tobacco advertising, anti-tobacco public service announcements, and news coverage of tobacco issues) on adult attitudes toward tobacco control (Blake 2010a), and on efforts to regulate the portrayal of smoking in movies (Blake 2010b). In addition, I recently co-authored a book chapter titled “Media and Population Health” in the Sage Handbook of Media Processes and Effects (2009).

(50) My teaching experience includes serving as a teaching fellow for graduate-level courses at the Harvard School of Public Health and the Harvard John F. Kennedy School of Government, including “Health Promotion through Mass Media,” “Public Opinion, Polling, and Public Policy,” and “Society and Health.”

(51) I am the recipient of several awards and honors related to my scholarship and applied work in health communication. These include four Awards of Merit from the National Institutes of Health; four “Plain Language” awards from the National Institutes of Health; and numerous academic fellowships and scholarships.

(52) I serve as an ad-hoc peer reviewer for the Journal of Health Communication; for Social Science & Medicine, and for the American Journal of Health Promotion.

(2010), issued on August 17, 2006, ordered the Defendants to publish and disseminate court-approved corrective statements on five specific topics. The Court found that requiring the Defendants to make such corrective statements was “appropriate and necessary to prevent and restrain them from making fraudulent public statements on smoking and health matters in the future” (page 926).

(54) The Court ordered the Defendants to publish corrective statements in newspapers and disseminate them through other channels such as television, cigarette package onserts,

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retail displays, advertisements, and on the Defendants’ corporate Web sites. It ordered the corrective statements to address:

• the Defendants’ manipulation of cigarette design and composition to ensure optimum nicotine delivery; and

• the adverse health effects of exposure to secondhand smoke (also known as environmental tobacco smoke or ETS) (pages 938–39).

(55) In its 2006 order, the Court directed the parties to submit proposed corrective statements within 60 days, and the parties did so.

(56) After several years on appeal, the case was returned to the District Court in 2010 for further consideration—including the corrective statements it ordered, but did not specify—in its 2006 Final Order. My understanding is that the Court has given all parties the opportunity to conduct research to support their 2006 proposed corrective statements, or to support any new corrective statements they wish to propose.

(57) In August 2010, the U.S. Department of Justice (DOJ) asked the U.S. Department of Health and Human Services (HHS or DHHS) for guidance on how best to proceed on the corrective statement remedy. In response to DOJ’s request, HHS assembled health communication and tobacco control scientists from several components. I have been a part of this effort since it originated.

(58) I am a Federal employee with the National Cancer Institute. I have been charged with providing a foundation of evidence to aid the Court’s decision on the corrective statements to impose. I have been asked to evaluate the proposed corrective statements submitted to the Court in 2006 by the cigarette manufacturers and the Public Health Intervenors, and to develop and test a set of potential new corrective statements.

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(59) Under my direction, both qualitative and quantitative techniques were utilized to evaluate the proposed corrective statements on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) behavioral intentions around quitting smoking and staying quit in current and former smokers.

(60) I also assessed how the proposed corrective statements may be differentially received and understood by several segments of the U.S. population, including youth (aged 14–17) and adults (aged 18+); English- and Spanish- dominant speakers; current, former, and never smokers; people of different races and ethnicities; and individuals of low socioeconomic status.

(61) I assessed to what extent, if any, the proposed statements may have unintended consequences such as boomerang effects (e.g., causing smoking urges or negatively affecting behavioral intentions to quit or stay quit in current and former smokers) and to what extent the proposed statements may affect how people would respond to future misrepresentations about the health consequences of smoking.

(62) While working on this matter, I was assisted by a staff of tobacco control and communication scientists and statisticians from NCI, in addition to staff and researchers from the social marketing firm Salter>Mitchell and the survey research firm Knowledge Networks. I was also assisted by administrative and scientific staff from Information Management Systems and BLH Technologies, Inc. Additionally, over the course of my research, I consulted occasionally with staff members at FDA and CDC.

(63) I directed the activities of the research staff, made all final decisions concerning the analytic methodologies and their implementation, and prepared this report. My analysis is ongoing and I reserve the right to consider additional data and review additional information, and to amend and supplement this report, all research contained herein, and my opinions and testimony.

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(64) I am not being compensated for my time and efforts beyond my regular salary. I have not previously testified as an expert at trial or by deposition.

IV. MATERIALS CONSIDERED

(65) In forming my opinion, I relied on materials provided to me by counsel or gathered by me or at my direction, including existing published research in my field of study and studies involving corrective statement evaluations. Documents that I have considered in forming my expert opinion and preparing this report are listed in Appendix B.

V. CORRECTIVE STATEMENTS STUDY

V.1. Introduction

V.1.i. Formative Research

(66) Focus group and survey research endeavors are standard mechanisms for understanding audience behaviors, intentions, attitudes, and knowledge about various topics; these techniques are routinely used to devise health communication campaigns and health education messages and to provide researchers with an assessment of the campaign or message. Formative research is research conducted during the development of messages to better understand the target audiences, the factors that shape their behavior, and the best ways to reach them. Formative research involves the pre-testing of potential media communications to assess whether these communications are conveying their intended messages and to gauge target audiences response.

V.1.ii. Background

(67) Media exposure is associated with health attitudes, knowledge, and behavior, and accurate knowledge has been a central component of effective health promotion in several areas.

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(68) Knowledge of the risks associated with tobacco use is not evenly distributed in the population. In particular, individuals with low SES (using income, education, and occupation as markers of SES) are significantly more likely to believe myths about smoking and hold inaccurate beliefs about the risks of smoking.

(69) Despite the success of several large-scale public health campaigns, there is evidence that some public health campaigns, including those with mass media components, have had ambiguous or no effects (e.g., the Stanford Five City Program and the COMMIT project).

Moreover, there is evidence that some public health campaigns have resulted in unintended consequences such as boomerang effects and knowledge gaps.

(70) Boomerang Effects are a phenomenon wherein significant portions of a mass media campaign’s target audience are influenced in the opposite direction from what is intended.

(71) The Knowledge Gap Hypothesis documents a long-held observation that absent some conditions, the flow of information on a given topic can lead to differential learning among members of certain population groups, delineated by SES, race and ethnicity, and geographic area. A related concept, communication inequality, posits that differences in the way health information is created and distributed among and across groups can create knowledge gaps among those that do and do not receive adequate exposure to health information.

(72) These unintended consequences underscore the need to carefully pre-test messages, plan for their dissemination, and conduct process evaluation. Message testing is the single best method to guard against counterproductive features of health communication endeavors that may produce undesired responses.

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V.1.iii. Approach

(73) Under my direction, my colleagues and I utilized both qualitative and quantitative techniques to evaluate the proposed corrective statements on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) behavioral intentions around quitting smoking and staying quit in current and former smokers.

(74) I also assessed how the proposed corrective statements may be differentially received and understood by several segments of the U.S. population, including youth smokers and nonsmokers (aged 14–17) and adults (aged 18+); English- and Spanish-dominant speakers; current, former, and never smokers; people of different races and ethnicities;

and individuals of low socioeconomic status.

(75) I assessed to what extent, if any, the proposed statements may have unintended consequences such as boomerang effects (e.g., causing smoking urges or negatively affecting behavioral intentions to quit or stay quit in current and former smokers) and to what extent the proposed statements may affect how people would respond to future misrepresentations about the health consequences of smoking.

V.1.iv. Institutional Review Board (IRB)

(76) The research described herein was deemed exempt for adult participants by the NIH Office of Human Subjects Research Protections (#5486). Research with youth underwent full IRB review and approval by NCI’s Special Studies Institutional Review Board (Protocol #11-C-N067).

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V.2. Phase I: Qualitative Evaluation

V.2.i. Aims

(77) In Phase I, NCI contracted with the social marketing firm Salter>Mitchell (S>M) to conduct focus groups to test a series of potential corrective statements for use in United States v. Philip Morris USA, Inc.

(78) Focus groups are a form of qualitative research that utilizes group interactions to assess how and why people think a certain way about a given topic or issue. A focus group study typically involves convening several small, homogeneous groups of people of similar backgrounds and experiences to discuss a particular topic or issue of interest to the researchers. Most focus group studies involve conducting several focus groups consisting of approximately 4 to 8 people with each lasting approximately 1–2 hours.

Focus group studies are usually accompanied by another research method, such as surveys or in-depth interviews, and are especially useful when researchers wish to facilitate discussion of open-ended questions. This study utilized both focus group and survey research methods to evaluate the proposed corrective statements related to this case.

(79) The objective of this phase of research was to assess potential statements with intended target audiences to evaluate message comprehension and the potential for negative, unintended consequences such as boomerang effects, smoking urges, and knowledge gaps. The overarching goal of this phase of the research was to get in-depth feedback from people representing key target populations, in order to:

• Compare different potential corrective statements to determine which were the most effective at communicating desired areas of information.

• Winnow and enhance statements prior to a subsequent quantitative research phase.

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V.2.ii. Methodology

Participant Recruitment

(80) Focus group participants were recruited in English and Spanish using a customized screener (see Appendix D2 and Appendix D6). Adult participants consented to participation, and youth participants provided assent after parental consent was obtained (see Appendix D3). All study participants were paid a monetary incentive of $75.

Focus Group Structure

(81) A total of eight focus groups were conducted to test the corrective statements with current, never, and former smokers of low socioeconomic status (SES) and average/high SES, Spanish-language dominant Hispanic adults, and teens aged 14–17 (smokers and nonsmokers). The focus groups were conducted between November 18 and December 2, 2010, in Baltimore, Maryland, and Orlando, Florida. Sample characteristics of the eight groups are provided below.

Table V1. Focus Groups Sample Characteristics

No. of

participants

Median

Age Gender Race/Ethnicity

Current Smokers

8

39

4 men; 4

women

6 Caucasian; 2 African

American

Current Smokers,

Low Socio-economic status

8 47 5 men; 3

women

5 Caucasian; 3 African

American

Never/Former Smokers 8 37 4 men; 4

women

6 Caucasian; 2 African

American

Never/Former Smokers,

Low Socio-economic status

8 39 3 men; 5

women

6 Caucasian; 2 African

American

Nonsmoker Teens,

aged 14-17

8 15 4 men; 4

women

6 Caucasian; 1 African

American; 1 Hispanic

Current Smoker Teens, aged 14-17 6 16 4 men; 2

women

4 Caucasian; 2 African

American

Hispanic, Current Smokers 8 43 4 men; 4

women

8 Hispanic

Hispanic, Never/Former Smokers

8 39 4 men; 4

women

8 Hispanic

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(82) For the purpose of recruiting for this study, low socio-economic status was defined as a combination of having an education level of high school graduate or less, and a household income of under $35,000.

(83) Adult focus groups were conducted among never/former smokers and among current smokers, as defined below:

• Adult never smokers were defined as individuals who reported they had not smoked 100 cigarettes in their lifetime.

• Adult former smokers were defined as individuals who reported they had ever smoked 100 cigarettes in their lifetime and that they now do not smoke.

• Adult current smokers were defined as individuals who reported they had ever smoked 100 cigarettes in their lifetime and that they now smoke either daily or on some days.

(84) Teen focus groups were conducted among nonsmokers and smokers, as defined below:

• Teen nonsmokers were defined as individuals who reported they had never tried cigarette smoking, and individuals who reported they had tried cigarette smoking but had not smoked on any of the last 30 days.

• Teen smokers were defined as individuals who reported they had ever tried cigarette smoking and had smoked on at least 1 day of the last 30.

(85) Focus group participants’ identifying data were kept confidential. Audio recordings were made of the focus group discussions and were later transcribed.

(86) Thirty corrective statements were evaluated, covering the five topic areas ordered by the Court, with six statements tested for each topic area. Focus group participants were unaware of the sources of the corrective statements they were asked to evaluate. The qualitative effort also was used to winnow the field of proposed corrective statements and potentially enhance the newly developed statements prior to a quantitative research phase.

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(87) For purposes of ranking the corrective statements, the first two focus groups (current smokers, low SES focus group and never/former smokers focus group) did the exercise collectively and arrived at a group consensus, whereas subsequent groups did the ranking individually. This change in procedure was made to shorten the exercise length and ensure all discussion topics could be covered in the allotted time for the focus groups.

(88) The sources of the corrective statements tested in Phase I are as shown below. The first five sets were submitted to the Court in 2006. The sixth was prepared by the National Cancer Institute in conjunction with S>M for this project, and is referred to as the “NCI statement” or “NCI.”

1 At DOJ’s direction, some modifications were made to the Public Health Intervenors’ 2006 proposals before testing.

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(90) Both the order of the topics and the order of the statements were randomized within each focus group, as well as across all focus groups.

(91) Participants were asked to give feedback on statements from the six different sources in all five topic areas. Participants were asked to read and identify the main idea of each potential corrective statement. They were then asked to rank the statements within each topic area according to how clearly each communicated the corrective area topic, how well it caught their attention, and how much it would impact them personally.

(92) The 90-minute focus group discussions—moderated by members of the Salter>Mitchell research team—covered the following domains in the order described below:

1. Unaided main ideas of all statements

2. Within each corrective topic area, respondents ranked the applicable statements based on how well each communicated the desired topic area information goal (the adverse health effects of smoking, the addictiveness of smoking and nicotine, etc.).

a. When ranking the statements, study participants were asked to consider:

i. How easy the statement was to understand,

ii. Whether they would pay attention to it, and

iii. Whether they thought it would have any lasting impact on them.

3. A discussion of reasons for the rankings, including the following:

a. Each statement’s likely impact on smoking perceptions and behaviors,

b. Whether there was anything confusing in the statements,

c. The believability of the statements,

d. Whether the statements contained new and/or relevant information, and

e. How likely they would be to believe future “opposite claims.”

4. A discussion of the impact of the introductory text in some of the statements, expressly saying they were being issued as a result of a court order, as compared to other statements that did not reveal that information.

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5. A discussion of the impact of text in some of the statements, saying they were being sponsored by a particular cigarette manufacturer, as compared to other statements that did not reveal that information.

V.2.iii. Results

Phase I Summary of Findings

(93) Qualitative research is exploratory in nature and not intended to provide data that are quantifiable or “projectable” to a stated population. Rather, it is typically used to elicit reactions and ideas from participants about a particular topic in order to generate insights that can inform strategic decisions.

(94) A summary of results from Phase I is provided below:

(95) Participants in the focus groups felt the Intervenors’ statements communicated messages more clearly than others. Participants said these statements attracted their attention the most. They preferred statements that were direct and concise over statements that were long or wordy. While teens and Hispanics responded similarly to the general population groups, there was more variability within the teen and Hispanic groups than within the other focus groups.

(96) Participants used words like “scare tactics” to describe some of the statements proposed by the cigarette manufacturers that included long lists of diseases and conditions.

(97) Most participants commented on the “shocking” nature of some of the information in the statements, particularly of those citing the adverse health effects of smoking on the individual and adverse effects of secondhand smoke on the health of the fetus and on children.

(98) Participants generally made a distinction between lists of health hazards (diseases) and statistics about deaths. Lists of diseases were viewed as messages they are already used to

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seeing while statistics about deaths seemed to strike participants more as facts rather than possibilities. Many participants felt that statements that avoided excessive medical language were easier to understand.

(99) While reporting they learned new information from the corrective statements in general, current smokers rarely said that any of them would make them think about quitting smoking. Nonsmokers, however, did believe the statements would have an impact on nonsmokers, perhaps to prevent individuals from starting to smoke.

(100) There was little indication that any of the statements would spark negative unintended consequences such as encouraging nonsmokers or former smokers to smoke; however, smoking urges in current smokers were not recorded directly as part of the assessment.

Other unintended consequences, such as knowledge gaps or resistance to messages, were not observed.

(101) Participants generally reported that after reading the statements they would be unlikely to believe opposite future claims.

(102) Participants in the teen focus groups generally understood all the terms in the statements.

Some admitted they would ignore these statements because they were long and detailed.

In general, teens responded positively to the inclusion of the Surgeon General as a source of information and the “court-ordered” language. They seemed, however, slightly more skeptical of its credibility than did older participants.

(103) Having a corrective statement say that it was “court ordered” was widely considered a positive attribute, and gave the statement more credibility. However, virtually all respondents reacted negatively to excessive use of legal language.

Specific Findings for the Five Corrective Topic Areas

(104) The focus group results for each of the five corrective topic areas are discussed in turn below. Each discussion concludes with a data table that provides the focus group rank

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frequencies for each statement. Given the number of potential corrective statements under study, the focus group rank frequencies were helpful to providing directional guidance on which statements to use in the subsequent quantitative phase of the study.

For this reason, particular attention is given to isolating those statements that were consistently ranked near the bottom, hence the summary of the aggregate rankings for fifth and sixth place. Although the rankings are shown in numeric tables, it is not appropriate to interpret the data in a strictly quantitative sense.

(106) The Intervenors’ statement (A-5) stood out to general audience participants as a good example of information presented in a concise manner. Participants felt the Intervenors’ statement was credible and the death statistics were new information for them:

• “…This one is giving you things that you can directly relate it to like more people die from smoking than murder, AIDS, suicide, drugs, car crashes, and alcohol combined.” [About the Intervenors’ statement (A-5)]

(107) Some participants felt the NCI statement (A-6) condensed the more striking points into a shorter, more easily absorbed message. They liked the NCI statement’s brevity and directness.

(108) Participants often mentioned information about pregnant women and children aloud, which may indicate that it stood out to them from the other information included.

(109) Scare tactics were perceived in the statements that listed the harms of smoking at length. General audience participants felt that the Lorillard statement (A-4) was too long. They did not take much away from the BATCo statement (A-1) other than needing to find the information yourself and some participants said it did not grab their attention.

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(110) Importantly, the word “causal”—used most frequently in the Lorillard statement (A-4) — was often read as “casual” by a number of participants; this word may be misinterpreted and cause confusion for audiences. For example:

• “And there’s a casual relationship, so it’s saying smoking is kind of related to all of this stuff …”

(111) Hispanic participants most valued statements that provided new information. Reporting that they learned more about the death toll caused by cigarettes from the Intervenors’ and NCI statements (A-5 and A-6), they rejected the Philip Morris and RJ Reynolds statements (A-2 and A-3) for not offering any new information.

(112) The Intervenors’ statement (A-5) initiated more conversation about death statistics than did the Lorillard statement (A-4):

• “I was more shocked by the fact that there’re more deaths related to smoking than murders and suicides. I didn’t know that.”[Hispanic participant, about the Intervenors’ statement (A-5)]

(113) Also, the BATCo statement (A-1) was widely regarded, in this and in other topics (B-1, C-1, etc.) to be devoid of any direct information. Participants in all groups felt the main message of most of the BATCo statements to be: “If you want to know something, go and find out yourself.”

(114) In the teen groups, the information that stood out the most was “smoking kills 1,200 Americans each day,” in the NCI statement (A-6). The death statistics provided in the Intervenors’ statement (A-5) were also striking to members of these groups. One comment participants made differentiated between consequences and statistics. While potential consequences conveyed possibilities they reported, statistics were less likely to be ignored because they were more factual:

(115) Teen participants ranked the BATCo and RJ Reynolds statements (A-1 and A-3) as the least clear and lowest impact statements while the Intervenors’ statement (A-5) was at the top of the rankings. They liked the statistical information included in the Intervenors’ statement (A-5) and found the Lorillard statement (A-4) too long, likening it to schoolrelated reading:

• “I don’t think some of the ones that list all the consequences and these people are just going to look as possibilities but when they say that the statistics and facts of how many people die and how the dangers of it compared to other diseases and stuff like that, that you can’t ignore that.”[Teen participant]

Topic A: Rankings and Recommendations

(116) Despite close rankings, Salter>Mitchell recommended eliminating the Lorillard statement (A-4) from Phase II, and keeping the Philip Morris statement (A-2). This was because the Lorillard statement follows nearly identical structure and content as the RJ Reynolds statement (A-3) (both cite and draw heavily from the same Surgeon General’s Report).

Salter>Mitchell concluded that assessing a different message structure—in this case, the Philip Morris statement—would deepen understanding more than evaluating two relatively similar statements. I concurred.

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(117) The BATCo statement (A-1) was thought to be the least effective at relaying this area of information and was also recommended for elimination from the next phase of research. I concurred with this recommendation as well, and did not put the Topic A Lorillard or BATCo statements in the testing pool for Phase II of the study. The statements dropped from further examination based on the focus group phase of the study are shaded in the rankings table below.

Table V2. Negative Health Effects of Smoking Focus Group

Rankings (Topic A)

1st 2nd 3rd 4th 5th 6th

BATCo (A-1) 0 0 2 3 5 38

Philip Morris (A-2) 4 4 14 3 20 3

RJ Reynolds (A-3) 1 9 11 20 7 0

Lorillard (A-4) 10 7 8 6 11 6

Intervenors (A-5) 30 9 6 3 0 0

NCI (A-6) 3 19 7 13 5 1

Specific Findings for Topic B: Addictiveness of Smoking and Nicotine

(118) The specific statements tested for Topic B: Addictiveness of Smoking and Nicotine are shown in the S>M qualitative-phase report (Appendix C2), at page 22.

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(119) Participants had mixed responses about whether they learned something new from this set of statements. Some participants reported learning that it can take more than will power to quit smoking, while other participants reported already knowing that. They responded positively to the admission of manipulation and lying from cigarette manufacturers.

There was a feeling among some participants that the Intervenors’ statement (B-5) might not stop smokers from smoking but might make smoking unattractive for nonsmokers.

Most participants felt the BATCo statement (B-1) did not offer any new or interesting information about the addictiveness of nicotine and tobacco. Other statements, like the one offered by Lorillard (B-4), offered information that they said is already widely available to and known by the public.

• “It doesn’t have any shock factor for me. I mean I already felt that way from when I came in the door.” [About the Lorillard statement (B-4)]

• “It tells you that it’s hard to quit, that it’s addictive and that it affects your brain.”

[About why they chose Intervenors’ statement as the top in this group (B-5)]

(120) In general, the corrective statements about addiction seemed to spark feelings of guilt in some participants who were smokers and made some of them feel defensive. A few participants who were smokers stated that the Philip Morris statement (B-2) made them not want to attempt to quit smoking because the statement said it was very difficult to do so.

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(121) Participants in the Hispanic focus groups felt that these corrective statements generally conveyed the same message they’ve always heard about the addictiveness of cigarettes.

They noted that the Surgeon General had arrived at a conclusion about the addictiveness of cigarettes. The BATCo statement (B-2) did not resonate with Hispanic participants, who ranked it below all other statements, because it did not offer any new or striking information. They liked that the Intervenors’ statement (B-5) was phrased as a retraction by the cigarette manufacturers regarding the definite addictiveness of cigarettes, saying it gave the statement more credibility. One Hispanic participant, though, expressed skepticism about the potential impact of any of the addiction statements:

• “I don’t think it’d have such a strong impact because all this information is like, you could say it’s not the first time you hear this. Smoking is addictive, we all know that. They manipulate it to be addictive, we all know that. It’s different to see it in black and white, but it won’t cause an impact.” [Hispanic participant, during dialogue about the Intervenors’ statement (B-5), but about all the addiction statements in general]

(122) Participants in the teen focus groups generally understood that the main idea of these corrective statements was the addictiveness of nicotine. Adding the source of the statements (by naming a cigarette manufacturer), they said, made them more reliable. The BATCo statement (B-1) was ranked at the bottom because, teen participants said, it’s the same message they’re already hearing. The Intervenors’ statement (B-5) was ranked at the top in the teen nonsmokers group while Lorillard and NCI (B-4 and B-6) were ranked at the top in the teen smokers group:

(123) Teen respondents reported that they had not previously been aware of the information in the Intervenors’ statement on addiction (B-5) that nicotine changes the brain. (The Intervenors’ statement on manipulation (D-5) also includes this information.) Teen smokers said that this statement would not change their intentions about quitting

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smoking, but at the same time, also reported that it would not make them give up hope of ever quitting:

• “Honestly I don’t really usually pay attention to [communications located in]

stores. If I saw it on TV, I don’t think I’d pay attention either.” [Teen participant, about the Lorillard statement (B-4)]

Topic B: Rankings and Recommendations

(124) Despite close rankings, Salter>Mitchell recommended excluding the RJ Reynolds statement (B-3) and keeping the Philip Morris statement (B-2) in Phase II of the study, for the same reasons cited for Topic A. The BATCo statement (B-1) was also recommended for elimination based on its low rankings. I concurred with these assessments, and did not include the Topic B RJ Reynolds and BATCo statements in Phase II. The statements dropped from further examination based on the focus-group phase of the study are shaded in the rankings table below.

(126) Participants understood the underlying message of these statements, which was that cigarettes cause the same amount of damage regardless of type. There was nothing reported as confusing in any of these statements.

(127) Some participants liked the Intervenors’ statement (C-5) because it identified the manufacturer sponsoring the statement, saying that lent a feeling of honesty to the statement. For others, the NCI statement (C-6) resonated because they felt it was simple and straightforward; some participants ranked this as the top statement because it was concise and direct. The BATCo statement (C-1) was considered the most clear in one general audience group for explicitly stating the corrective topic subject matter. Some participants preferred the Philip Morris statement (C-2), reporting it was the most direct.

(128) Some participants also responded strongly to the “truth” language in the NCI statement (C-6) (“A Federal court is requiring tobacco companies to tell the truth about smoking.

Here’s the truth:…”) while others preferred the language in the Intervenors’ statement (C-5) starting with “We falsely marketed low tar and light cigarettes as less harmful… Here’s the truth…”. The direct admission to misleading the public generated the strongest negative feelings toward cigarette manufacturers of any statement in this topic area.

(129) Many participants found the low tar statements provided information that was new to them:

• “I knew cigarettes weren’t good for you, but I figured that they [‘low tar,’ ‘light,’ etc. cigarettes] were a little bit healthier for you and maybe the tobacco was a little bit healthier for you.” [About learning something new]

(130) In the Hispanic focus groups, the low tar statements offered much new information as many participants reported being unaware that, regardless of type, all cigarettes cause the same amount of damage to a person’s health. Hispanic participants understood the main idea of all the statements in this topic to be “there is no cigarette that won’t kill you”; the

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overall message conveyed was smokers can smoke any kind of cigarette – regular versus light or cheap versus expensive—because “it’s all the same.” For example:

• “This [the statement] has been done under order by the District Court, done by the cigarette company itself and in it they are saying “we falsely market these cigarettes.” Just with that they are telling us, it’s all a scam. There’s no difference at all. When they say light, medium, low, it’s all the same with a different package. That’s what they’re saying in a few words. It’s coming from their own mouth. When they do marketing they get to say lies, here they have to tell the truth by Federal order.” [Hispanic respondent]

(131) Teen participants reported that the information that all cigarettes cause the same amount of harm was clearly conveyed in all the corrective statements. Teen participants reportedly learned new information about how all cigarettes cause the same harm regardless of their type. The Intervenors’ statement (C-5) was set apart by presenting facts in bullet form and that cigarette manufacturers were admitting they were wrong to market some types of cigarettes as less harmful. Some teen participants liked the NCI statement (C-6) for its directness and the Philip Morris statement (C-2) for its simplicity.

(132) Teen focus-group participants ranked the RJ Reynolds, Lorillard and BATCo low tar statements (C-3, C-4, and C-1) at the bottom. Some participants in both the teen smoker and nonsmoker groups felt that the proposed corrective statements on this topic might lead smokers to stop buying light cigarettes and smoke regular cigarettes instead. Teen smokers felt, however, that the corrective statement in this topic would not have influenced their decision to start smoking in the first place.

• “I like the part of [the Intervenors’ statement (C-5)] how they’re admitting they were falsely advertising that the cigarettes were light so they didn’t have as much nicotine or tar in them. That’s why I placed [it] up top for me. So, if they’d put like that junk on [the Philip Morris statement (C-2)], it’d make a difference for me.”[Teen participant].

statements from further testing in the quantitative phase, based on their low rankings. I concurred, and did not put the Topic C BATCo or RJ Reynolds statements forward for testing in Phase II. The statements dropped from further examination based on the focusgroup phase of the study are shaded in the rankings table below.

(137) Similarly, Hispanic participants felt that the Intervenors’ statement (D-5) best described the intent of this corrective topic. These groups reported that the bullets made each point clear and the “court-ordered” language lent the statement credibility.

(138) The terms for and meaning of the word “tar” in Spanish was discussed in some detail in the Hispanic focus groups. Different terms are used in different countries of origin. There was also some confusion over what exactly the statements said was being manipulated.

Some participants in these groups felt the statements were about cigarette companies’ manipulating customers into buying more cigarettes, while others felt the statements were about manipulating nicotine levels. Although some participants did understand that the statements meant that levels of nicotine were being manipulated, they did not agree about what that meant. Illustrative are these three responses from Hispanic participants who were asked to state the main idea of the Spanish-language version of the BATCo statement (D-1):

• Participant 1: “Manipulating the design to market to children.”

• Participant 2: “Manufacturers manipulating people.”

• Participant 3: “The way they induce people to buy cigarettes.”

(139) Teen participants felt the Intervenors’ statement (D-5) was the easiest to understand while other statements did not deliver the message clearly. Some participants felt the Intervenors’ statement could be improved if it were shorter. Teen participants reported that the “Federal court order” language at the end made the Intervenors’ statement (D-5) more believable.

• “[The Intervenors’ statement (D-5)] tells you exactly what they’re doing as in manipulating the chemicals inside to make it more addicting. And it puts it in a plain manner instead of selling straight facts like it came from a computer.”[Teen participant]

II. The BATCo statement (D-1) was also recommended for exclusion based on its low rankings. I concurred, and did not put the Lorillard or BATCo Topic D statements forward for future testing. The statements dropped from further examination based on the focus-group phase of the study are shaded in the rankings table below.

(141) The specific statements tested in the focus-group phase for Topic E, the adverse health effects of exposure to secondhand smoke, are shown in the S>M qualitative-phase report (Appendix C5), at pages 25–26.

(142) Some general audience participants felt that this topic contained little new information, while others felt the number of chemicals found in secondhand smoke was something new. Again, information about harm to children seemed to start dialogue in some groups.

(143) The Intervenors’ statement (E-5) was ranked at the top because its messages about “the truth” and information about the number of chemicals resonated with participants. Some participants ranked the NCI statement (E-6) at the top because of the death statistics it included, although a few participants felt the 38,000 figure was low compared with their expectations.

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(144) Some participants felt that the NCI statement (E-6) summarized the important points better than the Intervenors’ statement (E-5) because it was shorter to read while still including all the pertinent information. Participants felt the NCI statement (E-6) might make nonsmokers more aware of their surroundings and the environments to which they take their children. Participants felt the Lorillard statement (E-4) was too lengthy to keep peoples’ attention, saying it read like a pharmaceutical advertisement listing the side effects of a drug:

• “Being more conscious, if you are a smoker, who you smoke around. And if you’re not, keeping your kids away from people who smoke or places where there might be smoke. Make it safer.”[About the effects of the Intervenors’ statement (E-5)

• “The part that made the least impact to me was you should rely upon your medical provider and the Surgeon General making decisions regarding smoking.

That had the least impact. I like the here’s the truth, hey these guys made us tell you.”[Participant comparing statements from cigarette manufacturers to those of the Intervenors and NCI.]

(145) Participants in the Hispanic groups felt the Intervenors’ statement (E-5) was the most shocking as it conveyed that cigarettes contain a large number (4,800) of chemicals, although one participant said that this message was already being sent through television.

They also chose this statement because it showed that smoking affects the nonsmoker’s health as well as the smoker’s. The added information about the court order seemed to again help the credibility of this statement.

• “It’s something different because it says not only the harm you’re doing to yourself. It already says that, but the harm you’re doing to others.” [Hispanic participant, about the Intervenors’ statement (E-5)]

(146) The BATCo statement (E-1) caused some confusion because of its use of the abbreviation ETS for environmental tobacco smoke, rendered as HTA (humo de tabaco ambiental) in Spanish. Participants in the Hispanic groups also felt that the BATCo statement was more about finding information than about secondhand smoke. Some

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participants in the Hispanic groups said that the Philip Morris statement (E-2) contained some new information, specifically that secondhand smoke causes illness; they said this was important information that the public should be made aware of. For the RJ Reynolds statement (E-3), participants in the Hispanic groups focused on the information about children. They thought the Lorillard statement (E-4) cautioned the smoker against smoking near nonsmokers. Participants in the Hispanic groups felt that the Intervenors’ statement (E-5) focused on the chemicals cigarettes contain. They reported that the NCI statement (E-6) touched on the point that tobacco companies were admitting to the effects of secondhand smoke:

• “And most of all, it causes the same kind of damage for kids as if it was an adult who was smoking.” [Hispanic participant, about the Philip Morris statement (E-
2)]

(147) Teen smokers noted aloud the information that pregnant women and children were harmed by secondhand smoke. This portion of the secondhand smoke statements seemed to jump out at them. The fact that cigarette smoke contains many chemicals also resonated with teen participants.

(148) Teens placed the BATCo statement (E-1) at the bottom of the list based on its brevity, lack of clarity, and inability to attract their attention. The RJ Reynolds, Philip Morris, and Intervenors’ statements (E-3, E-2, and E-5) were ranked at the top of the list for these groups. Statements that included facts and examples and were direct and easy to understand resonated well with teen participants:

• “It gives examples of each thing like, the chemicals it contains and what it does to you and how even second hand smoke affects others.” [Teen participant, about why the Intervenors’ statement (E-5) most clearly communicated the message]

Topic E: Rankings and Recommendations

(149) Salter>Mitchell recommended dropping the BATCo and Lorillard statements (E-1 and E-4) from further testing, due to their low rankings. I concurred with this recommendation, and eliminated the Topic E BATCo and Lorillard statements from the

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pool of statements to be tested in Phase II. The statements dropped from further examination based on the focus-group phase of the study are shaded in the rankings table below.

(150) The primary aim of Phase II was to use an experimental design to evaluate the proposed corrective statements with a nationally representative sample of adults and teens on (a) cognitive outcomes such as knowledge, beliefs, confusion, trust, and future beliefs; (b) statement attributes such as attention and clarity of message; and (c) smoking urges and behavioral intentions around quitting smoking and staying quit in current and former smokers.

(151) The secondary aim of the quantitative phase of the study was to explore any observed, broad patterns of effect modification in order to evaluate the potential for the corrective statements to be received differentially in the population based on smoking status, income, age, or race/ethnicity, given the disproportionate levels of tobacco advertising and smoking prevalence within and across populations. (Effect modification tests the interaction between two variables, to examine whether observed effects are different by different levels of a third variable.)

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V.3.ii. Methodology

Data Collection

(152) In December 2010, NCI contracted with the survey research firm Knowledge Networks (KN) to conduct an online survey with a nationally representative sample of U.S. adults and teens. Details on KN’s panel recruitment are available in Appendix E3. Households were sampled from the KN KnowledgePanel, a probability-based Web panel. One adult per selected household was invited to participate in the study. If the household contained multiple teens, more than one teen was invited to participate.

(153) For the current study, KN used its profiling information to determine invited respondents’ Federal poverty level, smoking status, race/ethnicity, language proficiency, and availability of teenager aged 14 to 17 in the household.

(154) The Federal poverty level differs by year and by state of residence. In 2010, the 200% Federal poverty level for the 48 contiguous states and the District of Columbia was a gross annual income of $44,100 for a family of four. (A different Federal poverty level is calculated for Alaska and Hawaii.)

(155) Smoking status of adults and teens was further assessed at baseline using the following measures. Adults were asked: “Have you smoked at least 100 cigarettes in your entire life?” and “Do you now smoke cigarettes every day, some days, or not at all?” Never smokers were defined as those answering “no” to the first question; former smokers were defined as those answering “yes” to the first question and “not at all” to the second question; and current smokers were defined as answering “yes” to the first question and “every day” or “some days” to the second question. Teens were asked: “Have you ever tried cigarette smoking, even one or two puffs?” and “During the past 30 days, on how many days did you smoke cigarettes?” Teen never smokers were defined as answering “no” to the first question; teen former smokers were defined as answering “yes” to ever trying cigarette smoking and answering “zero days” to the second question; teen current smokers were defined as answering “yes” to trying cigarette smoking and smoking at least one day in the past month.

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(156) The target population for the KN survey consisted of:

• Current smokers above the 200% Federal poverty level, aged 18 and over

• Current smokers at or below the 200% Federal poverty level, aged 18 and over

• Former smokers and never smokers above the 200% Federal poverty level, aged 18 and over

• Former smokers and never smokers at or below the 200% Federal poverty level, aged 18 and over

• African Americans, aged 18 and over

• Predominantly Spanish speaking Hispanics, aged 18 and over

• Teenagers aged 14 to 17

Informed Consent

(157) All adult respondents consented to the KnowledgePanel and also provided their consent before proceeding to the NCI survey. For the teen sample, parents provided consent for their teens to be contacted and interviewed, and the teens provided their assent to participate in the survey.

Incentives

(158) In addition to standard measures taken by KN to enhance survey cooperation, the following steps were also taken to increase response rates:

• Email reminders to non-responders were sent on the third day of the field period.

• An incentive of points with a cash-equivalent of $5 was offered to increase response rates in populations oversampled in order to achieve adequate representation for comparative analyses (i.e., African American sample, Spanish dominant sample, and teenage sample).

• Other participants were eligible to win an in-kind prize through a standard monthly KN sweepstakes.

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Pilot Survey

(159) Pilot surveys are small-scale tests of a near-final survey instrument, generally conducted with small samples that mirror the demographic composition of the target population.

Typically only small samples are necessary—15 pilot respondents are sufficient for a short and straightforward questionnaire, whereas 25 may be needed for long, complex questionnaire.

(160) Prior to the launch of the full data collection effort, from December 23 to December 27, 2010, a pilot survey was conducted at my direction with 30 respondents from the KN panel to ascertain whether all technical elements of the online survey were working properly, and to verify assumptions about the length of the survey and the qualification incidence of study respondents.

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(161) This opportunity was also used to include additional questions on the pilot instrument to assess comprehension of the more complex survey items, particularly on the two questions about future beliefs. These additional questions were presented to pilot-study respondents immediately after they had answered the future beliefs questions. See below.

and “natural” cigarettes has the same health risks as smoking full-flavor cigarettes; if topic=D, insert: tobacco companies manipulate cigarette design; if topic=E, insert: secondhand smoke is harmful to other people], would you:

a. Believe that it is not proven that [if topic =A, insert: smoking cigarettes is bad for your health; if topic=B, insert: smoking and nicotine are addictive; if topic=C, insert: smoking “low tar,”

“light,” “ultra light,” “mild,” and “natural”

cigarettes has the same health risks as smoking full-flavor cigarettes; if topic=D, insert: tobacco companies manipulate cigarette design; if topic=E, insert: secondhand smoke is harmful to other people].

cigarettes has the same health risks as smoking full-flavor cigarettes; if topic=D, insert: tobacco companies manipulate cigarette design; if topic=E, insert: secondhand smoke is harmful to other people].

c. That statement would have no impact on whether I believe that [if topic =A, insert: smoking cigarettes is bad for your health; if topic=B, insert:

“mild,” and “natural” cigarettes has the same health risks as smoking full-flavor cigarettes; if topic=D, insert: tobacco companies manipulate cigarette design; if topic=E, insert: secondhand smoke is harmful to other people].

(162) Data from the pilot survey indicated that most respondents were able to comprehend the future beliefs questions. Nonetheless, as an added measure, the response options were revised to add a “not sure” response category in the final instrument.

Field Period & Survey Length

(163) Median time for participants to complete the main survey was 20 minutes. The data collection field periods for the pilot survey and main survey were as follows.

Table V8. Data Collection Field

Periods

Stage Start Date End Date

Pilot Survey

12/23/2010

12/27/2010

Main Survey

12/31/2010

1/10/2011

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Survey Completion, Sample Sizes, and Sample Characteristics

(164) The number of respondents sampled and participating in the survey and the survey completion rates are presented in Table V9. The sample characteristics are presented in

Table V10.

Table V9. Survey Response and Completion Rates

Sample Groups Invited

Responded

(consent and

no consent) Completed

% Responded

(# responded/

#invited)

% Complete

(#completed/

#responded)

Current smokers above

200% Federal poverty

level

800

513

469

64

91

Current smokers at or

below the 200% Federal

poverty level

800

432

364

54

84

Former/never smokers

above 200% Federal

poverty level

800

557

499

70

90

Former/never smokers at

or below the 200%

Federal poverty level

800

406

359

51

88

African American

1800

1050

991

58

94

Spanish proficient

924

342

322

37

94

Teens 14–17

2400

940

613

39

65

Total

8324

4240

3617

51

85

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Sample Characteristics

Table V10. Sample Characteristics

Message Testing for Tobacco-Related Corrective Statements

Study, 2011 N=3617

N

Unweighted

Percent Weighted Percent

Smoking Status

Current smoker 1,014 28.0 20.6

Former smoker 794 22.0 25.7

Never smoker 1,809 50.0 53.7

Incomei

≤ 200% FPL 1,429 39.5 28.1

>200% FPL 2,188 60.5 71.9

Educationii

No high school degree 321 8.9 12.9

High school degree or

GED

923 25.5 30.6

Some college or college

degree

2,373 65.6 56.5

Gender

Female 2,043 56.5 52.0

Male 1,574 43.5 48.0

Age

14–17 613 16.9 7.2

18–30 410 11.3 21.2

31+ 2,594 71.7 71.6

Race/Ethnicity

African American 1,187 32.9 12.2

Hispaniciii 551 15.2 13.7

White 1,704 47.1 67.8

Other race 175 4.8 6.3

iIncome of parent was used to assign teen (14–17 year olds) income values.

iiEducation of parent was used as a proxy for teen (14–17 year olds) education values.

iiiSpanish-dominant Hispanics (N=322) were shown all corrective statements and survey questions in Spanish.

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Corrective Statements Tested, by Topic Area

(165) Within each topic area, the five statements under study (chosen based on results from the Phase I study) included two from tobacco industry, one from the Intervenors, one from NCI, and one control condition (a Surgeon General’s warning). Participants were unaware of the sources of the corrective statements they were asked to evaluate.

The Surgeon General has concluded: Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction.

These conclusions are contained in the 1988 Surgeon General’s Report. [Cigarette Manufacturer Name] encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

Intervenors

We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and all it takes to quit is willpower. Here’s the truth:

• Smoking is very addictive. And it’s not easy to quit.

• We manipulated cigarettes to make them more addictive.

• When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District court.

NCI

Tobacco companies testified before Congress that nicotine isn’t addictive. Now a Federal court is requiring them to tell the truth about smoking. Here’s the truth:

• The nicotine in cigarettes is highly addictive. Cigarettes can be harder to quit than heroin and cocaine.

• Nicotine changes people’s brains so they crave cigarettes the same way they want food when they’re hungry and water when they’re thirsty.

• The result: People keep buying cigarettes long after they wish they had quit.

There is no safe cigarette. “Low tar,” “light,” “ultra light,” “medium,” and “mild”

brands are no exception. You should not assume that these brands are safe or safer than full flavor brands or that smoking these brands will help you quit. If you are concerned about the health risks of smoking, you should quit.

Industry 2:

Lorillard

The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigarette Manufacturer Name], 449 F. Supp. 2d 1, 928, 938-39 (D.D.C. 2006), aff’d in part and vacated in part, 566 F.3d 1095 D.C. Cir. 2009) (per curiam), cert. denied, 561 U.S. ___, 130 S. Ct. 3501 (2010). The Surgeon General has concluded:

• Smoking cigarettes with lower machine-measured yields of tar and nicotine (including those that have been labeled “low tar,” “light,” “ultra light, “mild”

and “natural”) provides no clear benefit to health in comparison to smoking cigarettes with higher machine-measured yields of tar and nicotine.

This conclusion is contained in the 2004 Surgeon General’s Report. [Cigarette Manufacturer Name] encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

Intervenors

We falsely marketed “low tar” and “light” cigarettes as less harmful than regular cigarettes to keep people smoking and sustain our profits.

We knew that many smokers switch to “low tar” and “light” cigarettes rather than quitting because they believe “low tar” and “lights” are less harmful. They are NOT.

Here’s the truth:

• Just because lights and low tar cigarettes feel smoother, that doesn’t mean they are any better for you. Light cigarettes can deliver the same amounts of tar and nicotine as regular cigarettes.

Cigarettes deliver tar and nicotine. Well-known design features affect the delivery of tar and nicotine. The amount of tar and nicotine you inhale will vary, depending upon how you smoke. Generally speaking, the more intensely you smoke a cigarette, the more tar and nicotine you will inhale.

Industry 2:

RJ Reynolds

A United States District Court has found that:

• “Cigarettes are specifically designed to deliver a range of nicotine doses so that a smoker can obtain her optimal dose from virtually any cigarette on the market, regardless of that cigarette’s nicotine delivery level as measured by the FTC method.”

• “Cigarette manufacturers controlled the amount and form of nicotine delivery in commercial products by controlling the physical and chemical make-up of the tobacco blend and filler.”

This message is furnished pursuant to a Court Order by [Cigarette Manufacturer Name].

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

Intervenors

For decades, we denied that we controlled the level of nicotine delivered in cigarettes.

Here’s the truth:

• Cigarettes are a finely-tuned nicotine delivery device designed to addict people.

• We control nicotine delivery to create and sustain smokers’ addiction, because that’s how we keep customers coming back.

• We also add chemicals, such as ammonia, to enhance the impact of nicotine and make cigarettes taste less harsh.

• When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District court.

NCI

A Federal court is requiring tobacco companies to tell the truth about cigarette smoking.

Public health officials have concluded that secondhand smoke from cigarettes causes disease, including lung cancer and heart disease, in non-smoking adults, as well as causes conditions in children such as asthma, respiratory infections, cough, wheeze, otitis media (middle ear infection), and Sudden Infant Death Syndrome.

Industry 2:

RJ Reynolds

The Surgeon General has concluded:

• Exposure to environmental tobacco smoke has been proven to cause premature death and disease in children and in adults who do not smoke.

Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is taken from the 2006 Surgeon General’s Report.

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

Intervenors

For decades we denied the harms of secondhand smoke.

Here’s the truth from the U.S. Surgeon General and National Cancer Institute:

• Secondhand smoke has been proven to cause lung cancer and heart attacks and kills over 38,000 Americans each year.

• There is no risk-free exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District court.

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NCI

A Federal court is requiring tobacco companies to tell the truth about cigarette smoking.

Here’s the truth:

• Secondhand smoke kills 38,000 Americans every year.

• Children exposed to cigarette smoke suffer more from asthma, pneumonia, bronchitis, and ear infections. Adults exposed also suffer because they inhale the same chemicals from secondhand smoke that kill and disable smokers.

(166) Demographic information was collected before the survey, upon acceptance to the KN panel. Then, baseline smoking status questions were asked for adults and teens based on the standard assessment described previously, as well as questions about smoking behavior. Participants were also asked baseline questions assessing general knowledge related to the five topic areas: (a) knowledge about the negative effects of smoking; (b) knowledge about the addictiveness of smoking and nicotine; (c) knowledge about “low tar” cigarettes; (d) knowledge about cigarette design manipulation; and (e) knowledge about the negative effects of secondhand smoke. Other survey items assessed constructs such as smoking urges, tobacco-specific knowledge, risk perceptions, future beliefs related to opposite claims, attention, confusion, potential for public impact, and credibility. See Appendix E1 and E2 for the full survey instrument. Where possible, all constructs were assessed using 2-item measures with reliability and validity data available from other surveys.

(167) See the Corrective Statement Survey Flow (Figure V16) below for survey design and randomization. The total sample size was N=3,617. Upon completion of baseline measures, participants were randomly assigned to three of the five possible topic areas, and were randomly assigned to see one statement per topic area, totaling three statements.

After forced exposure to each of the three randomly assigned statements, respondents were asked a series of questions related to confusion, smoking urges, knowledge, and future beliefs. For this section of the survey, the sample size for each topic area was approximately 2,075. (Sample size for topics and outcomes varied across survey implementation due to randomization patterns, smoking status, and refused or missing responses on some items.)

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Figure V16. Corrective Statement Survey Flow

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(168) In the next section of the survey, participants were randomized to see statements from one of the two topic areas they had not been previously assigned, and were exposed to all five statements within that topic area (four proposed corrective statements and the control statement). Statement order was randomized to avoid order effects. For each of the five statements within the assigned topic area, participants answered questions related to attention, potential for public impact, and credibility. For each of these measures, the total sample size in each topic area was approximately 3,460. In this section, participants were also asked to rank the statements from 1 to 5, with 1 being the statement that most clearly communicated about the assigned topic. In assigning rankings, participants were also asked to consider the likelihood that the statement would capture their attention and how easy it was to understand. For the rankings task, total sample size in each topic area was approximately 700.

(169) In the final section of the survey, participants were exposed to one of five proposed introductory sentences related to source attribution and one of four proposed concluding sentences related to sponsorship, in order to assess the extent to which the proposed introductory sentences garnered attention and trust, and the extent to which the proposed concluding sentences affected trust, independent of the corrective statement text. The total sample size of respondents seeing the introductory sentences was N=3,578, with each introduction being seen by approximately 715 respondents. The total sample size of respondents seeing the concluding sentences was N=3,589, with each concluding sentence being seen by approximately 900 respondents.

Statistical Analysis

(170) A complete case analysis was utilized. Tests of significance were estimated at the p<0.05 level with 95% confidence intervals. Categorical response options were combined to create dichotomous outcomes (e.g., strongly agree/agree versus disagree/strongly disagree). To adjust for unequal probabilities of selection due to the complex sampling design and oversampling of African Americans, Spanish-dominant Hispanics, and teens,

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and to adjust for potential nonresponse bias, I used SUDAAN, a widely used statistical software package ideal for the analysis of complex surveys, to apply weighting factors to all estimates. See Appendix E3 for Knowledge Networks’ sample weighting documentation.

(171) I first calculated weighted percentages for statement rankings within topic areas to get a general sense of how participants ranked the statements on their ability to clearly communicate about the assigned topic.

(172) Bivariate analyses (crosstabulation with Chi Square) were conducted to evaluate associations between exposure to corrective statements and all outcome variables under study.

(174) To explore whether any of the statements may produce differential effects in populations of interest in the areas of knowledge, attention, and credibility, I added interaction terms to three of the main effects models, and modeled separately the interaction between statement and smoking status, statement and income, statement and age, and statement and race/ethnicity. Each of these effect modification models included all control variables and the higher-order main effects variables for statement, smoking status, income, age, and race/ethnicity, respectively.

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(175) To assess the impact of the corrective statements on future beliefs, I calculated weighted percentages by statement for respondents reporting that, if they were later to hear an opposite claim, they either would or would not believe it, it would have no impact on their beliefs, or they were not sure. Similarly, after exposing respondents to a corrective statement on a particular topic, they were asked subsequently if hearing that information in the same topic area “has not been proven” would affect their belief that the corrective statement topic had or had not been proven, whether the “not proven” claim would have no impact on their beliefs, or if they were not sure.

(176) To evaluate the impact that source attribution and sponsorship information might have on attention and trust, independent of the corrective statements, I calculated weighted percentages of respondents reporting that they strongly agreed or agreed that the proposed introductory sentence or concluding sentence would make them trust in or pay attention to the corrective statement that it introduced or followed. To evaluate predictors of attention and trust, I used multivariable logistic regression to model the predicted probability that attention and trust in the introductory and concluding sentences was associated with smoking status and sociodemographic characteristics of the respondents.

V.3.iii. Results

Overview

(177) The results of the quantitative analyses of the experimental study are described in this section. Results are organized by corrective statement topic, with the exception of general observations provided in the overview summaries below. Within each topic area, results are described for global rankings of the corrective statements; comparisons for specific statements versus the control condition on key outcome measures, adjusting for covariates; evaluation of the observed effect of specific statements on smoking urges and behavioral intentions among current and former smokers; and exploratory examinations of broad patterns of effect modification by target population. The section concludes with results related to source attribution and sponsorship, examining the possible influence of proposed introductory and concluding sentences on attention and trust.

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Summary of Findings

(178) Across nearly all topic areas and key outcome variables, the statements proposed by the Intervenors and the National Cancer Institute generally performed better than those proposed by the tobacco industry, both when compared to the control condition, and when ranked against all proposed statements under study. This pattern was particularly evident on outcome variables seen as highly relevant to this evaluation—accurate knowledge, attention, and potential for public impact.

(179) The exploratory analysis of potential differential effects on knowledge, attention, and credibility by target populations revealed no broad patterns of effect modification by smoking status, income, age, or race/ethnicity, though statistically significant interaction terms were noted for a few individual interaction variables. I report some of these potentially interesting findings, though they should be interpreted with appropriate caution, given that tests for moderating effects were a secondary objective of the study, and given that no clear patterns emerged wherein any particular statement was consistently received differentially by some population groups compared to others. I believe that the main effects models are the most robust, and provide the most insight into the proposed statements’ performance.

(180) Results detailed below, by topic area, will not discuss how individual proposed corrective statements performed on the measure of confusion (“How confusing, if at all, would you say that this statement was for you to understand?”). This is because higher levels of confusion were widely reported across all topic areas for nearly all proposed corrective statements than for the control condition (a Surgeon General’s warning). This finding is not surprising given that all the proposed corrective statements contain more detailed information than the Surgeon General’s warning and, given the wide dissemination of the Surgeon General’s warning, the likely familiarity of the text for many individuals in the study. These results are not seen as indicating a problem related to the comprehension of the proposed statements, especially because in bivariate analyses, nearly all statements in all topic areas had majority agreement that they were “not at all confusing.”

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(181) Our measures of triggering smoking urges in current and former smokers indicated only two significant results across all topic areas and statements; specifically, the Intervenors’ and NCI secondhand smoke statements were positively associated with triggering smoking urges in current and former smokers. Despite these two instances, I do not report major concerns regarding the corrective statements’ potential to cause smoking cravings among current and former smokers.

(182) Two questions assessed the effect of the proposed statements on future beliefs, with the first of these questions asking how the participant would respond if they later heard an “opposite claim,” and the second asking how they would respond if they later heard that a corrective topic area “has not been proven.” Global tests of statistical significance revealed only limited evidence that some statements performed better than others on the future beliefs questions. That few significant differences were found on these measures may be related to two factors. First, across most topics and statements, very few individuals reported they would no longer believe the corrective-statement information if future claims were to contradict the information; the vast majority of respondents had the “correct” response to these items across topics and statements. Exceptions were noted in the low tar and design manipulation topic areas. Second, one particular response option for the two future belief questions (the option, “This statement would have no impact” on the participant’s future beliefs) was selected by more participants than might have been expected. That result may suggest that many participants found this response option ambiguous or open to interpretation. Given these potential issues, I report weighted percentages and recommend that the future beliefs estimates be interpreted with appropriate caution. Measures for accurate knowledge, potential for public impact, and attention are also good indicators of future beliefs, and I point the Court to those estimates throughout this section.

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Topic A: Negative Health Effects of Smoking

Rankings for Topic A: Negative Health Effects of Smoking

(183) Respondents were randomized to see all 5 statements in Topic A. After viewing all 5 statements addressing the negative health effects of smoking, participants were asked to rank the statements in order from 1 (Best) to 5 (Worst) with regards to how well each statement communicated the dangers of smoking. As part of the ranking process, participants were asked to consider whether they would pay attention to the statement and how easy it was to understand. The results presented in Figure V17 represent the weighted percentage of people who ranked a specific statement either #1 or #2. In Topic A, the statement developed by the Intervenors was ranked highest, followed by the statement developed by NCI.

(184) Fully adjusted estimates of these variables are presented in Table 2A and Table 3A in Appendix C1.

(185) In Topic A, participants were asked how much they agreed or disagreed with the basic knowledge measure, “Cigarettes are bad for your health.” On this measure, the NCI statement performed statistically significantly better than control. No other negative health effects statements had statistically significant findings for the accurate knowledge construct. I saw no evidence of effect modification and no evidence that any of the statements performed significantly better than control on measures of credibility.

(186) Three negative health effects statements were associated with increased attention compared to control; the corrective statements proposed by Philip Morris, the Intervenors, and NCI performed better on attention. The same pattern was observed for the perceived potential public impact of the statement; in particular, on these three statements’ potential usefulness in “changing other people’s attitudes about smoking.”

No broad patterns of effect modification were observed.

Future Beliefs for Topic A: Negative Health Effects of Smoking

(187) See Table 4A in Appendix C1. Few individuals reported that they would believe an opposite claim or that they would believe that the information in the statement “had not been proven.” For all negative health effects statements, more than 50% of the respondents said that they would not believe the opposite claim.

(188) See Table 5A in Appendix C1. Among current and former smokers, no statistically significant differences were found between exposure to any of the proposed statements and the control condition on measures of smoking urges. Likewise, for current smokers, compared to the control condition, none of the negative health effects statements were associated with a significant difference in thinking about quitting smoking. For former

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smokers, only the NCI statement was significantly associated with increased intention to stay abstinent from smoking.

Topic B: Addictiveness of Smoking and Nicotine

Rankings for Topic B: Addictiveness of Smoking and Nicotine

(189) Respondents were randomized to see all five statements in Topic B. After viewing all five statements addressing the topic of addiction, participants were asked to rank them in order from 1 (Best) to 5 (Worst) with regards to how well each statement communicated the addictiveness of smoking and nicotine. As part of the ranking process, participants were asked to consider whether they would pay attention to the statement and how easy it was to understand. The results presented in this Figure V18 represent the percentage of people who ranked a specific statement either #1 or #2. In this topic area, the statement developed by NCI was ranked highest, followed by the statement developed by Intervenors.

Accurate Knowledge, Attention, Potential for Public Impact, Credibility for Topic B: Addictiveness of Smoking and Nicotine

(190) See Table 2B and Table 3B in Appendix C2. In response to the knowledge question about the addictiveness of smoking and nicotine, no statistically significant differences were seen between the statements and the control, nor did any of the statements have broadly observed differential effects in effect modification models.

(191) On credibility, statistically significant differences were noted, wherein individuals who saw Lorillard, Intervenors, or NCI addictiveness statements were less likely to believe the statement was true than participants who saw the control statement. Among current smokers, those who saw the statement proposed by Lorillard were more likely to say it was believable than never and former smokers; however, no broad patterns of effect modifications were observed for any of the tested statements.

(192) On the construct of attention, respondents seeing the Philip Morris and Lorillard addictiveness statements reported less attention than those seeing the control condition. In contrast, those seeing the statements by the Intervenors and NCI reported increased attention compared to control.

(193) Individuals who saw either the Philip Morris or Lorillard statement were significantly less likely to report that it had potential for public impact, compared to individuals assigned to the control.

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Future Beliefs for Topic B: Addictiveness of Smoking and Nicotine

(194) See Table 4B in Appendix C2. Few individuals reported either believing a future opposite claim or believing that the information in the addictiveness statement had not been proven. For all addictiveness statements except that from Lorillard (48.9%), 50% or more participants said that they would not believe an opposite claim. Similarly, although only approximately 48% of the respondents stated they would believe the statement by the Intervenors had been proven, more than 50% reported that they would believe the current statement had been proven for all other statements.

Smoking Urges and Behavioral Intentions for Topic B: Addictiveness of Smoking and Nicotine

(195) See Table 5B in Appendix C2. Among current and former smokers, no statistically different differences were found between any of the statements and the control for smoking urges being elicited by the specific statement.

(196) The proposed statements from Philip Morris and Lorillard related to the addictiveness of smoking and nicotine significantly decreased intentions to quit smoking among current smokers by about 65% compared to current smokers who saw the control statement.

(197) Respondents were randomized to see all 5 statements in Topic C. After viewing all 5 low tar statements, participants were asked to rank them in order from 1 (Best) to 5 (Worst) with regards to how well each statement communicated information about the lack of health benefit from “low tar,” “light,” “ultra light,” “mild,” and “natural” cigarettes. As part of the ranking process, participants were asked to consider whether they would pay attention to the statement and how easy it was to understand. The results presented in

Figure V19 represent the percentage of people who ranked a specific statement either #1 or #2. In this topic area, the statement developed by the Intervenors was ranked highest, followed by the statement developed by NCI.

(198) See Table 2C and Table 3C in Appendix C3. In response to items assessing knowledge of the lack of health benefits from “low tar” and “light” cigarettes, individuals who saw the Philip Morris statement were significantly more likely to endorse the correct answer to one of the outcome variables compared to those who saw the control. No other significant main effects for knowledge were noted. Exploratory analyses for effect modification indicated that for current smokers and individuals living at or below 200% of the Federal poverty level, the statement proposed by the Intervenors was associated with higher accuracy on one of the knowledge items.

(199) For the first credibility item, statistically significant positive differences were noted for all of the statements compared to the control, although on the second item the Lorillard statement was associated with less reported trust than the control statement. No broad patterns of effect modification were noted for credibility.

(200) Statistically significant positive associations were found between the attention variables and the statements proposed by Philip Morris, the Intervenors, and NCI compared to the control statement. The statement from the Intervenors was positively associated with both attention variables. Increased attention by current smokers to the Lorillard statement and decreased attention among African American and Hispanic individuals to a variety of the statements were noted in the analysis of potential effect modification, though no clear patterns can be discerned.

(201) With regards to perceived potential usefulness of the statements for public impact, significant differences in the positive direction were noted for all statements compared to control.

(202) See Table 4C in Appendix C3. Consistent with results from previous topic areas, few respondents said they would either believe a future opposite claim or believe that the information in the statement had not been proven. However, for this topic area, more

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variability was demonstrated. Only 37.4% of those who saw the Lorillard statement reported that they would not believe a future opposite claim and only approximately 29% of those exposed to the Lorillard statement or the control statement reported that they may later believe the current statement had been proven.

(204) Respondents were randomized to see all five statements in Topic D. After viewing all five statements addressing the Manipulation of Cigarette Design topic area, participants were asked to rank the statements in order from 1 (Best) to 5 (Worst) with regards to how well each statement communicated information about the manipulation of cigarette design by the manufacturers. As part of the ranking process, participants were asked to consider whether they would pay attention to the statement and how easy it was to understand. The results presented in Figure V20 represent the percentage of people who ranked a specific statement either #1 or #2. The design manipulation statement developed by the NCI was ranked highest, followed by the statement developed by Intervenors.

(205) See Table 2D and Table 3D in Appendix C4. The first question assessing knowledge about the manipulation of the design of cigarettes as a means to deliver nicotine asked for responses to the statement: “Cigarette makers add chemicals to cigarettes to make it easier for a smoker to get nicotine.” Individuals who saw the RJ Reynolds, Intervenors, or NCI statements were significantly more likely to answer “strongly agree” or “agree”

than those who saw the control. Similarly, respondents who saw the proposed statements from the Intervenors and NCI were significantly more likely to give positive responses to items related to attention and public impact.

(206) On issues of credibility, a statistically significant negative difference was noted for the Philip Morris statement and RJ Reynolds statement compared to control.

(207) The RJ Reynolds, Intervenors, and NCI statements all performed better than control on issues of attention. In contrast, the Philip Morris statement was negatively associated with attention compared to control.

(208) The statements proposed by both the Intervenors and NCI were positively associated with perceived potential for public impact.

(209) See Table 4D in Appendix C4. As demonstrated in other topic areas, few individuals endorsed either believing a future opposite claim or believing that the design manipulation information in the corrective statement had not been proven. However, the overall endorsement rates for the options associated with continuing to believe the design manipulation information were substantially lower than in the other topic areas. Less than 50% of respondents who were exposed to the Philip Morris, RJ Reynolds, or Intervenors’ statements reported that they would not believe the opposite claim. For all statements including the control, less than 50% of individuals said that they would still believe the information presented were proven if presented with opposite information in the future.

(210) See Table 6D in Appendix C4. No statistically significant differences were demonstrated for the elicited urges and behavioral intentions outcomes.

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Topic E: Adverse Health Effects of Secondhand Smoke

Rankings for Topic E: Adverse Health Effects of Secondhand Smoke

(211) Respondents were randomized to see all five statements in Topic E. After viewing all five statements addressing the adverse health effects of secondhand smoke, participants were asked to rank them in order from 1 (Best) to 5 (Worst) with regards to how well each statement communicated information about the health effects of secondhand smoke. As part of the ranking process, participants were asked to consider whether they would pay attention to the statement and how easy it was to understand. The results presented in

Figure V21 represent the percentage of people who ranked a specific statement either #1 or #2. In this topic area, the statement developed by the Intervenors was ranked highest, followed by the statement developed by NCI.

(212) See Table 2E and Table 3E in Appendix C5. All four statements were positively associated with accurate knowledge about the negative health effects of secondhand

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smoke compared to the control statement. No broad patterns of effect modification emerged.

(213) For the first credibility item, a statistically significant positive difference was noted for all of the proposed statements compared to the control. However, on the second credibility item, the Intervenors’ statement was negatively associated with trust compared to the control statement.

(214) Statistically significant positive associations were found between the second attention item and the statements proposed by Philip Morris, Intervenors, and NCI compared to the control statement, and all four statements were positively associated with perceived potential public impact compared to the control statement.

(215) See Table 4E in Appendix C5. As has been generally seen across the topic areas, few individuals reported either believing a future opposite claim or believing that the information included in the statement had not been proven. For all statements, approximately 50% or more of the respondents said that they would not believe the opposite claim.

(216) See Table 6E in Appendix C5. Following exposure to the Intervenors’ and the NCI secondhand smoke statements, current and former smokers were more likely to report increased urges to smoke compared to those who saw the control statement. No other statistically significant differences were noted for urges or behavioral intentions.

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Effects of Proposed Introductory Source Attribution Statements and Sponsorship on Attention to and Trust in Proposed Corrective Statements

(217) Outside the context of the text of the corrective statements, participants were asked to rate their attention to the proposed introductory source attribution statements. Figure V22 presents the weighted percentage of individuals who strongly agreed or agreed that their attention would be “grabbed” by the introductory source attribution statement. At least three fourths of the respondents strongly agreed or agreed that introductory source attribution statements 2 and 5 would “grab” their attention.

Additionally, participants were asked “how likely would you be to trust the [corrective]

statement, based on that introduction?” The results indicate that three introductory source attribution statements (2, 3, and 5) were perceived by about two-thirds of respondents as supporting the trustworthiness of the corrective statements (Figure V23).

*Introduction 1: “The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) Order #1010, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal)”

*Introduction 5: “Here’s the truth from the U.S. Surgeon General and the National Cancer Institute:”

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Figure V23. Source Attribution. Trust Rankings, by Statement

________________________________

*Introduction 1: “The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) Order #1010, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal)”

*Introduction 5: “Here’s the truth from the U.S. Surgeon General and the National Cancer Institute:”

(218) Predictors of attention and trust in the proposed introductory source attribution statements were modeled in multivariable analyses. See Appendix C6. Considering only the three introductory source attribution statements which were perceived the highest on trust and/or attention (2, 3, and 5), (a) former smokers and individuals with no high school degree reported significantly lower trust in corrective statements that would follow introductory statement 2, and current and former smokers and individuals age 18–30 reported lower levels of attention to introductory statement 2; (b) African Americans and individuals without a high school degree reported significantly higher attention, while females reported lower attention to introductory statement 3; and (c) current smokers reported a statistically significant lower level of attention to and trust in the corrective

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statements that would follow introductory statement 5, and individuals without a high school degree reported higher levels of attention to introductory statement 5.

(219) The Court’s Final Order requires that “The statements shall identify the Defendant making the corrective statements.” United States v. Philip Morris USA, Inc., 449 F. Supp. 2d 1 (D.D.C.), at page 940. Such “sponsorship” notices provide a means for the Court to confirm that each Defendant is complying with the Order. In addition, several studies in public opinion, public health, and communication research indicate that sponsorship information is important in order for audiences to assess credibility of messages. To evaluate the effects of different potential “sponsorship” sentences at the end of the corrective statements, I directed that several questions about this topic be included in the quantitative phase of the research.

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(220) Participants were asked to rate the impact that notices of sponsorship would have on their trust in the corrective statement. Figure V24 presents the percentage of individuals who strongly agreed or agreed that the sponsorship notice would make them trust the corrective statement. Sponsorship notice 2 was most highly ranked. The remaining three sponsorship notices were also endorsed by a majority of participants for their impact on trust in the corrective statement. Current smokers were statistically significantly less likely to report that they strongly agreed or agreed that sponsorship notice 3 would make them trust the corrective statement. See Appendix C6.

Figure V24. Sponsorship. Trust Rankings, by Sponsorship Notice

_____________________________________

* 1: “Paid for by [Cigarette Company Name] under order of a United States District Court.”

* 2: “This message is furnished by [Cigarette Company Name] pursuant to a Court Order and is taken from the 2004 Surgeon General’s Report.”

[Cigarette Company Name] encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.”

* 4: “This message is furnished pursuant to a Court Order by [Cigarette Company Name].”

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V.4. Discussion

(221) In evaluating the corrective statements proposed for United States v. Philip Morris USA, Inc., I used both qualitative and quantitative methods to examine the performance of the statements on a number of key outcome variables. This report has detailed the research undertaken to provide a foundation of scientific evidence to aid the Court’s decision on issuing the most effective corrective statements, and those with the least potential to have negative unintended consequences.

(222) Data gathered from eight focus groups (N=62) and a nationally representative survey (N=3,617) of adults and teens reveals that the proposed corrective statements remedy has strong potential to increase knowledge in the population, particularly in areas where there has been a dearth of information available in the public information environment.

(223) Accurate knowledge, attention, and perceived public impact are important markers of comprehension and should be used in considering the statements’ potential to “inoculate”

people against future misinformation. On measures of these constructs, several of the proposed statements performed significantly better than the control condition in the experimental study. I used the odds ratios on those constructs, as well as the overall statement rankings and observed potential for unintended consequences, as the primary considerations in making my recommendations. Consistency with impressions offered by focus group participants also was considered.

(224) Our data do not point to any serious concerns with negative unintended consequences related to the corrective statements that were tested. I saw no broad patterns of effect modification; none of the statements consistently performed poorly on measures of accurate knowledge, attention, and credibility with teens compared to adults, low SES individuals versus higher SES people, current versus never and former smokers, or individuals who are African American, Spanish-dominant Hispanic, or other race compared to Whites. Nonetheless, decades of research on mass communication efforts indicates that, due to social disparities in health information access, usage, and comprehension, there is always the potential for deficits in accurate knowledge to occur in vulnerable populations. This will be an important area to monitor as the corrective statements remedy is implemented at the population level.

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(225) Current and former smokers who saw the NCI and Intervenors’ statements in the secondhand smoke topic area were more likely to report smoking urges after exposure to those statements compared to current and former smokers who saw the control condition.

My recommendations take this unintended consequence into consideration.

(226) Similarly, the data reveal that in the topic area related to the addictiveness of smoking and nicotine, the Lorillard and Philip Morris statements were negatively associated with quit intentions among smokers compared to the quit intentions of smokers who saw the control condition. These findings also were taken into account in my recommendations.

V.5. Recommendations to the Court

Topic A: Negative Health Effects of Smoking

• Recommendation: National Cancer Institute

(227) While the NCI, Intervenors, and Philip Morris negative health effects statements all performed statistically better than the control condition on measures of attention and potential for public impact, the NCI statement was the only statement that performed statistically better than control on increasing accurate knowledge. It was also positively associated with behavioral intentions to stay quit among former smokers, and had the second highest global ranking in this topic area.

Topic B: Addictiveness of Smoking and Nicotine

• Recommendation: Intervenors

(228) The proposed statements from the Intervenors and NCI were significantly stronger than control on garnering attention in the topic area of addictiveness of smoking and nicotine.

The Intervenors’ statement had the second highest global ranking when respondents saw and rated all statements in this topic area, and was positively associated with behavioral intentions to stay quit among former smokers. In contrast, the Lorillard and Philip Morris statements were negatively associated with quit intentions among smokers, and they were also significantly less likely to have perceived potential for public impact. None of the proposed statements performed statistically better than control on increasing accurate knowledge.

(229) Making a recommendation for the low tar statements required a slightly more complex analysis. None of the proposed corrective statements produced unintended consequences, and nearly all the statements performed better than the control condition on measures of attention, potential for public impact, and credibility. The Philip Morris statement was the only statement to be positively associated with increasing accurate knowledge compared to control, but it ranked third among all the statements on the global rankings. The Intervenors’ and NCI statements ranked #1 and #2, respectively, on the global rankings.

While the Intervenors, NCI, or Philip Morris statements would be acceptable based on these data alone, the Intervenors’ statement proved stronger in two additional areas. First, in looking for broad patterns of effect modification, the data reveal that only the Intervenors’ statement had the potential to increase knowledge in current smokers and in low income populations, which are important populations for this particular topic area.

Further, in the qualitative phase of the study, the Intervenors’ statement far outranked both the NCI and Philip Morris statements.

(230) The statements proposed by NCI and the Intervenors performed equally well on constructs of interest and global rankings (#1 and #2, respectively). Both were significantly better than control on their perceived potential to have public impact, and they were both positively associated with increasing accurate knowledge, as was the RJ Reynolds statement. The Intervenors’ statement, however, far outranked the NCI statement among focus group participants, and was particularly well-received in the Spanish-language and teen focus groups. Both the Philip Morris and RJ Reynolds statements were negatively associated with trust compared to control. None of the statements in this category produced notable unintended consequences.

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Topic E: Adverse Health Effects of Secondhand Smoke

• Recommendation: RJ Reynolds

(231) Nearly all statements in the secondhand smoke topic area performed statistically better than control on measures of knowledge, attention, potential for public impact, and credibility. Despite being ranked #1 and #2, respectively, in the global rankings, the Intervenors’ and NCI statements were positively associated with triggering smoking urges after exposure compared to current and former smokers who saw the control condition. The RJ Reynolds statement ranked #3 in the global rankings and focus groups, but—unlike the Intervenors’ and NCI statements—was not associated with any unintended consequences, and performed as well as the other statements on constructs of interest when compared to the control condition.

(232) As such, the RJ Reynolds statement is the conservative choice for the secondhand smoke topic area. The Court might consider, however, that in this particular topic area, my findings related to smoking urges could be interpreted differently. It is possible that the Intervenors’ and NCI statements communicated the harms associated with secondhand smoke more clearly and were therefore more impactful, thus causing an indirect evocation of smoking urges due to eliciting an emotion such as anxiety. It is beyond the scope of the collected data to explore this possibility in a meaningful way.

Source Attribution and Sponsorship

(233) Based on my research, I identified one introductory source attribution statement and one sponsorship notice as performing better than the others. However, the research data that is currently available would not yet support the Court’s substituting these betterperforming introductory and concluding sentences across all of the five statements I am recommending. There are two reasons for this. The first is that the better-performing sponsorship notice references the 2004 Surgeon General’s Report; that source does provide information about the negative health effects of smoking, but it would be inaccurate to cite it as the source for all five topics.

(234) The second is that substituting a different introductory source attribution statement or sponsorship notice to a particular message has the potential to change the frame of the

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message for some people. Further study, using focus groups, would help to ensure that adjusting the introductory and concluding sentences would not change comprehension or attitudes towards the message in a substantive way.

(235) My analysis of the introductory source attribution statements was done out of the context of the corrective statements themselves. This was done in order to objectively evaluate the proposed introductory source attribution statements. With the exception of introductory statement 1 (“The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in…”), all the introductory statements rated relatively well on attention and trust and can be considered acceptable. Introductory statement 2 received the highest global rankings for attention and trust, followed by introductory statement 5. Therefore, introductory statement 2 is the most appropriate choice for source attribution. My recommendation, however, is that for each topic area, the recommended corrective statements remain intact for implementation, unless further focus group research can be conducted to confirm that changing the introductory sentences would not change the overall effect of the corrective statements on target populations.

• Best-Performing: Sponsorship Notice 2 (“This message is furnished by [Cigarette Company Name] pursuant to a court order and is taken from the 2004 Surgeon General’s Report.”)

(236) My analysis of the sponsorship notices was done out of the context of the corrective statements themselves, in order to objectively evaluate different sponsorship notices. All the sponsorship notices rated relatively well on trust and can be considered acceptable.

(237) My recommendation, however, is that for each topic area, the recommended corrective statements remain intact for implementation, unless further focus group research can be

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conducted to confirm that changing the sponsorship notice would not change the overall effect of the corrective statements on target populations. With the exception of the negative health effects corrective statement, each of the corrective statements I recommend contains a sponsorship notice approximating that ordered by the Court.

(238) Sponsorship notice 2 references the 2004 Surgeon General’s Report, which is appropriate for corrective statements under Topic A: Negative Health Effects. Should the Court choose to recommend that sponsorship notice 2 be required as part of the corrective statements remedy, the date of the Surgeon General’s Report will need to be modified based on the topic area to which it is attached. I am not aware of a Surgeon General’s Report that addresses cigarette design manipulation, so for Topic D, the sponsorship notice would need to be modified.

V.6. Next Steps

(239) Before implementation of the corrective statements remedy, the Court may wish to consider three further areas related to the Order issued in 2006.

Dissemination Channels

(240) There have been significant changes in the communication and media landscape since the Court’s Final Judgment and Remedial Order in August, 2006. The Order focused on the use of standard, traditional mass media outlets such as newspaper and television advertisements.

(241) Since 2006, there has been exponential growth in the use of new technologies and social media as both marketing and communication channels. Accompanying this growth has been a shift away from the use of traditional media as a means to reach target populations and to disseminate information effectively.

(242) Less than 1% of cigarette marketing expenditures are now used for advertising in traditional print media. Moreover, reliance on traditional sources of information has fallen dramatically. Current estimates indicate that less than 20% of the adult population reads national newspapers. Moreover, direct mail has increased in importance as a strategic dissemination tool.

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(243) Another major shift has been the emergence and widespread adoption of online social media platforms such as Facebook.

(244) Given this context, the Court may wish to consider that, in addition to the traditional dissemination channels outlined in the 2006 Order, nontraditional channels may be effective delivery mechanisms to ensure that the corrective statements reach their intended audiences. Such mechanisms may include direct mail, mobile media and social networking platforms such as Facebook, Twitter, blogs and YouTube.

Design Elements

(245) I would encourage the Court to establish guidelines on basic design elements such as font, font size and placement. Such efforts would ensure consistency throughout the implementation of the corrective statements remedy, as well as ensure readability of the corrective statements themselves.

Monitoring and Evaluation

(246) Within the highly dynamic context of the current health communication environment, it is appropriate and, indeed, a best practice within health communication science, to evaluate the impact of mass communication endeavors. Although it is vitally important to track basic elements such as exposure within intended audiences, it is strongly recommended that monitoring and evaluation go well beyond this to include a careful follow-up assessment of the extent to which the corrective statements are having their intended effects on key outcomes associated with the five corrective topic areas. Ideally, these outcomes should be assessed at multiple follow-up intervals. In my opinion, reach and impact of the corrective statements should be evaluated 1, 6, and 12 months after the statements’ initial launch.

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VI. CONCLUSION

(247) This report has described an evaluation of the proposed corrective statements based on a well-established formative research process that is broadly used within the field of health communication science. Based upon the research described in this report, the Court can feel confident that the recommended corrective statements are likely to capture attention, enhance accurate knowledge, have a positive impact on the public, and reduce the likelihood that consumers will believe potential future misrepresentations about the topics the Court identified. In addition, the study showed that the recommended corrective statements are not likely to cause negative, unintended consequences in the population. I hope that the recommendations prove helpful in the issuance of corrective statements for implementation.

Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2007.

Centers for Disease Control and Prevention. Designing and Implementing an Effective Tobacco Counter-Marketing Campaign. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2003.

Centers for Disease Control and Prevention. Tobacco Use Prevention Media Campaigns:

Lessons Learned from Youth in Nine Countries. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.

Cornfeld, R. S. “A New Approach to an Old Remedy: Corrective Advertising and the Federal Trade Commission.” Iowa Law Review 61 (1975–1976): 693–721.

U.S. Department of Health and Human Services, National Institutes of Health, 1989.

National Cancer Institute. The Role of the Media in Promoting and Reducing Tobacco Use, Tobacco Control Monograph No. 19. Bethesda, MD: U.S. Department of Health and Human Services, 2008. cancercontrol.cancer.gov/….

Pew Internet and American Life. “Media Consumption Has Changed Since 2000.” (June 24,
2010), www.pewinternet.org/Prese… Has-Changed-Since-2000.aspx.

*Introduction 5: “Here’s the truth from the U.S. Surgeon General and the National Cancer Institute:”

Unadjusted Percent

Age

Race/Ethnicity

iIncome of parent was used to assign teen (14-17 year olds) income values.

*Introduction 1: “The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) Order #1010, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal)”

The National Cancer Institute (NCI) partnered with Salter>Mitchell (S>M) to develop and assess a series of statements aimed at the general public to rectify beliefs and perceptions about smoking. This endeavor was initiated after a U.S. Federal Court ordered a series of “corrective statements” on information about smoking for the consumer public as a result of U.S. v. Philip Morris USA, Inc. The corrective statements are intended to target potential misperceptions resultant from past marketing and promotional practices undertaken by the tobacco industry.

This report includes findings from a qualitative assessment of several such corrective statements.

The overarching goal of this research was to get an in-depth assessment of feedback from individuals representing key target populations, specifically to gain insight into the following:

4. The manipulation of cigarette design and composition to ensure optimum nicotine delivery

5. The adverse health effects of exposure to secondhand smoke

In total, 62 members of the public shared feedback about the statements. The statements were tested in two U.S. markets—one in a state with an average prevalence of smokers and one with a higher prevalence according to CDC Behavioral Risk Factor Surveillance System data.3 1 Slight modifications were made to the corrective statements prepared by the Public Health Intervenors.

2 This additional set of corrective statements was created by Salter>Mitchell and the National Cancer Institute.

Adult focus groups were conducted among never/former smokers and among current smokers, as defined below:

• Adult never smokers were defined as individuals who reported they had never smoked 100 cigarettes in their lifetime.

• Adult former smokers were defined as individuals who reported they had ever smoked 100 cigarettes in their lifetime and that they now do not smoke.

• Adult current smokers were defined as individuals who reported they had ever smoked 100 cigarettes in their lifetime and that they now smoke either daily or on some days.

Teen focus groups were conducted among non-smokers and smokers, as defined below:

• Teen nonsmokers were defined as individuals who reported they had never tried cigarette smoking, and individuals who reported they had tried cigarette smoking but had not smoked on any of the last 30 days.

• Teen smokers were defined as individuals who reported they had ever tried cigarette smoking and had smoked on at least 1 day of the last 30.

Low socio-economic status was defined as a combination of having an education level of high school graduate or less, and also a household income of under $35,000. All study participants were paid a monetary incentive of $75 to compensate them for their time.

The flow of the 90 minute group discussions—moderated by members of the Salter>Mitchell research team—covered the following domains:

1. Unaided main ideas of all statements

2. Within each corrective topic area, respondents ranked the applicable statements based on how well each communicated the desired topic area information goal (the adverse health effects of smoking, the addictiveness of smoking and nicotine, etc.)

a. When ranking the statements, study participants were asked to consider:

i. How easy the statement was to understand.

ii. Whether they would pay attention to it.

iii. Whether they thought it would have any lasting impact on them.

3. A discussion of reasons for the rankings, including the following:

a. Each statements’ likely impact on smoking perceptions and behaviors

b. Whether there was anything confusing in the statements

c. The believability of the statements

d. Whether the statements contained new and/or relevant information

e. How likely they would be to believe future “opposite claims”

4. A discussion of the impact of the statements saying they were expressly being issued as a result of a court order, as compared to not revealing that context in the introductory text.

5. A discussion of the impact of the statements saying they were being sponsored by tobacco industry, as compared to not revealing that context in the closing text.

Key Findings

Comprehension of Message Elements

• Participants were attracted by messages that were concise and direct. Many participants felt the statements that avoided dense medical and legal language were easier to understand, and therefore more likely to be read and have an impact once in the marketplace.

• Lengthy lists of potential health effects from smoking were not considered to be new information or have a strong impact on participants. Conversely, some of the statistical facts included in the statements, particularly those relating to deaths or lesser known facts were new to number of respondents and seemed to resonate more strongly.

• Adding that the corrective statements were court ordered was widely considered a positive attribute, and gave the statements more credibility.

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Potential impact of statements

• Non-smokers believed the statements would have an impact on other non-smokers, specifically in preventing individuals from beginning to smoke.

• On the other hand, a number of participants who were current smokers, while acknowledging the strong impact of some statements, still reported that they would have little or no impact on whether they continued to smoke.

• There was no indication that any of the statements would spark unintended negative consequences.

• Participants generally reported that after reading the statements they would be unlikely to believe opposite future claims.

Findings specific to Hispanics and Teens

• While Hispanics and teens generally responded similarly to the general audience overall, there was less cohesion among these groups in terms of which statements were most effective. So while they tended to rank the same statements highest, it was by a smaller margin relative to the other participant groups.

• Participants in the teen focus groups generally understood all the terms in the statement messages as well as the adult participants.

• Teens more openly admitted they would ignore the lengthier statements as they were dense and highly detailed.

Implications for the next round of quantitative research

• Overall, the statements developed by the Intervenor group and Salter>Mitchell/NCI 2010 were most consistently regarded as the strongest communications of the corrective areas.

Both were therefore included in the quantitative study.

• Conversely, the statements submitted by BATCo. were felt to be the least effective at relaying the prescribed areas of information, so they were excluded from the next round of research.

• The performance of the statements from the remaining three companies—Philip Morris, RJ Reynolds and Lorillard—varied by topic so some statements were included, while others excluded.

o It should also be noted that the message content and structure for statements from RJ Reynolds and Lorillard were very similar (both cited and drew heavily from the same Surgeon General’s report). As such, in some instances where their performance was similar, we did not carry forward both statements into the quantitative study since we would in effect be testing the same stimulus.

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Based on the collective findings, the following organizations’ statements were carried forward into the quantitative portion of this research for further investigation. A full list of all statements can be found in Appendices A (English version) and B (Spanish version) of this report.

Corrective Topic Area

Adverse health

effects

Secondhand

smoke

Light, Low tar

etc

Addictiveness Manipulate

Nicotine

RJ Reynolds Philip Morris Philip Morris Philip Morris Philip Morris

Intervenors RJ Reynolds Lorillard Lorillard RJ Reynolds

S>M/NCI 2010 Intervenors Intervenors Intervenors Intervenors

Philip Morris S>M/NCI 2010 S>M/NCI 2010 S>M/NCI 2010 S>M/NCI 2010

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DETAILED FINDINGS

INTRODUCTION

The National Cancer Institute (NCI) partnered with Salter>Mitchell (S>M) to develop and assess a series of statements aimed at the general public to rectify beliefs and misperceptions about smoking. This endeavor was initiated after a U.S. Federal Court ordered a series of “corrective statements” on information about smoking for the consumer public as a result of U.S. v. Philip Morris USA, Inc. The corrective statements are intended to target potential misperceptions resultant from past marketing and promotional practices undertaken by the tobacco industry.

This report includes findings from a qualitative assessment of several such corrective statements. The overall objective of this phase of research was to assess potential statements with intended target audiences to evaluate message comprehension and the potential for negative unintended consequences such as boomerang effects, smoking triggers, or knowledge gaps. Thirty potential messages were evaluated, covering five main topic areas (six statements were tested per topic area).

The qualitative effort also was used to winnow and enhance potential statements prior to a quantitative research phase which will form the basis of NCI’s final recommendations.

METHODOLOGY

Corrective statements were tested with members of three key audiences: the general public, Hispanics (conducted in Spanish) and teens between November 18, and December 2, 2010.

The overarching goal of this research was to get an in-depth assessment of feedback from people representing key target populations, to specifically gain insight into the following:

• Compare proposed corrective statements to determine which were the most effective at communicating desired areas of information.

• Additionally, for this first stage of research we were also interested in winnowing and enhancing potential statements prior to a subsequent quantitative research phase.

In total, 62 members of the public shared feedback about the statements. The statements were tested in two U.S. markets—one in a state with an average prevalence of smokers and one with a higher prevalence according to CDC Behavioral Risk Factor Surveillance System data.4

Adult focus groups were conducted among never/former smokers and among current smokers, as defined below:

• Adult never smokers were defined as individuals who reported they had never smoked 100 cigarettes in their lifetime.

• Adult former smokers were defined as individuals who reported they had ever smoked 100 cigarettes in their lifetime and that they now do not smoke.

• Adult current smokers were defined as individuals who reported they had ever smoked 100 cigarettes in their lifetime and that they now smoke either daily or on some days.

Teen focus groups were conducted among non-smokers and smokers, as defined below:

• Teen nonsmokers were defined as individuals who reported they had never tried cigarette smoking, and individuals who reported they had tried cigarette smoking but had not smoked on any of the last 30 days.

• Teen smokers were defined as individuals who reported they had ever tried cigarette smoking and had smoked on at least 1 day of the last 30.

Low socio-economic status was defined as a combination of having an education level of high school graduate or less, and also a household income of under $35,000. All study participants were paid a monetary incentive of $75 to compensate them for their time.

In total, 30 corrective statements were tested with focus group participants. The statements tested included messages from tobacco companies as well as public health advocates and a social marketing

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agency. Each of the six organizations prepared one statement on each of five topics. The statements were prepared by:

• The manipulation of cigarette design and composition to ensure optimum nicotine delivery

• The adverse health effects of exposure to secondhand smoke Both the order of the topics and the order of the statements were randomized within each group, as well as across all focus groups.

Participants were recruited by an outside recruiting facility using a customized screener (this screener can be found in Appendices H and I to this report). Each participant read and signed a consent or assent form (see Appendices E, F and G).

Focus group participants’ identifying data were kept confidential. The focus group process was explained to all participants and researchers answered all their questions pertaining to the focus group process. Audio recordings were transcribed following the focus group discussions and these transcriptions were used by researchers to write this report and to develop recommendations for the next steps of this research project.

During the focus groups, participants were asked to give feedback on statements from the different sources in all five corrective areas. Participants were asked to read and identify the main idea of each statement of the corrective topics. They were then asked to rank the statements within each topic according to how clearly the corrective area was communicated, how well it caught their attention and how much it would impact them personally.

The flow of the 90 minute group discussions—moderated by members of the Salter>Mitchell research team—covered the following domains:

1. Unaided main ideas of all statements

2. Within each corrective topic area, respondents ranked the applicable statements based on how well each communicated the desired topic area information goal (the adverse health effects of smoking, the addictiveness of smoking and nicotine, etc.)

5 Slight modifications were made to the corrective statements prepared by the Public Health Intervenors.

6 This additional set of corrective statements was created by Salter>Mitchell and the National Cancer Institute.

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a. When ranking the statements, study participants were asked to consider:

i. How easy the statement was to understand.

ii. Whether they would pay attention to it.

iii. Whether they thought it would have any lasting impact on them.

3. A discussion of reasons for the rankings, including the following:

a. Each statements’ likely impact on smoking perceptions and behaviors

b. Whether there was anything confusing in the statements

c. The believability of the statements

d. Whether the statements contained new and/or relevant information

e. How likely they would be to believe future “opposite claims”

4. A discussion of the impact of the statements saying they were expressly being issued as a result of a court order, as compared to not revealing that context in the introductory text.

5. A discussion of the impact of the statements saying they were being sponsored by tobacco industry, as compared to not revealing that context in the closing text.

As a reminder to the reader, qualitative research is exploratory in nature and not intended to provide data that are quantifiable or “projectable” to a stated population. Rather, it is typically used to elicit reactions and ideas from participants about a particular topic in order to generate insights that can inform strategic decisions.

OVERALL FOCUS GROUP FINDINGS

• Overall, participants felt the Intervenors statements communicated messages more clearly than others. Participants said these messages attracted their attention the most among the other messages. They preferred statements that were direct and concise over statements that were too long or wordy.

• They used words like “scare tactics” to describe some of the messages that include long lists of diseases and conditions.

• While teens and Hispanics responded similarly to the general audience, there was less cohesion among these groups while there were more clear “winners” in the general audience group.

• Adding that the corrective statement was court ordered was widely considered a positive attribute, and gave the statement more credibility. However, virtually all respondents reacted negatively to excessive use of legal language.

• Participants generally made a distinction between lists of health hazards (diseases) and statistics about deaths. The former was viewed as messages they are already used to seeing while the latter seemed to strike participants more as facts rather than possibilities. Many participants felt the statements that avoided excessive medical language were easier to understand.

• Participants in all eight focus groups generally trusted the Surgeon General as a source of information. The name of the cigarette manufacturer neither added nor retracted credibility. The inclusion of this information, however, did spark some dialogue about the negative perception of cigarette manufacturers as uncaring businesses centered on sales.

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• Most participants commented on the shock value of some statements, particularly of those citing the adverse health effects of smoking on the individual and adverse effects of secondhand smoke on the health of the fetus and of children.

• While reporting they learned new information from the corrective statements in general, current smokers rarely said that any of these would make them stop smoking. Non-smokers, however, did believe the statements would have an impact on non-smokers, keeping individuals from beginning to smoke.

• There was no indication that any of the statements would spark unintended negative consequences.

• Participants generally reported that after reading the statements they would be unlikely to believe opposite future claims.

• Participants in the teen focus groups generally understood all the terms in the various statements as well as adults. Some admitted they would ignore these messages if they saw them in a store or on television, radio or the Internet as the statements were long and detailed. In general, they responded positively to the inclusion of the Surgeon General as a source of information and the “court ordered” language. They seemed, however, slightly more skeptical of its credibility than did older participants.

SPECIFIC FINDINGS FOR CORRECTIVE TOPIC AREAS

Within each topic area below, we will begin with a summary of the core prioritizing exercise included in the groups. As discussed earlier in this report, after capturing unaided top-of-mind reactions to the statements within each topic area, participants were informed of the overall communications goal for the topic and asked to rank them based on their effectiveness.

As an example, this is how the exercise for the “adverse health effects” topic was presented to participants.

Now you have 6 different statements in front of you. These statements are designed to communicate the adverse health effects of smoking.

What I want you to do is to rank them from 1 to 6 based on which statement most clearly communicates … The adverse health effects of smoking.

When I say MOST CLEARLY COMMUNICATES, I want you to again imagine that you were to see this statement in a newspaper, TV, online, or in a store, and I want you to take into account

• How easy is it to understand?

• Whether you would pay attention to it?

• And whether it would have a lasting impact on you?

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The results presented in the data tables that follow are the frequencies each statement was ranked in each position7. The intent is not to interpret the data in a strictly quantitative sense; rather, given the high number of statements that required assessment, we are using the results to provide directional guidance on which statements to focus on going forward. Particular attention was given to isolating those statements that were consistently ranked near the bottom, hence the summary of the aggregate rankings for fifth and sixth place.

Corrective Topic A: The adverse health effects of smoking

Recommendations

The statements submitted by BATCo. were felt to be the least effective at relaying this area of information, so they were excluded from the next round of research for this topic.

Additionally, and despite close rankings between the two, we recommended eliminating the Lorillard statement and keeping the Philip Morris statement. This was because the Lorillard message follows nearly identical structure and content as the RJ Reynolds message (both cite and draw heavily from the same Surgeon General report). Assessing a different message structure—in this case, the Philip Morris statement—will deepen our understanding more than evaluating two that are relatively similar.

Rankings 1st 2nd 3rd 4th 5th 6th

Summary of

5th/6th

BATCo 0 0 2 3 5 38 43

Philip Morris 4 4 14 3 20 3 23

RJ Reynolds 1 9 11 20 7 0 7

Lorillard 10 7 8 6 11 6 17

Intervenors 30 9 6 3 0 0 0

S>M/NCI 2010 3 19 7 13 5 1 6

Detailed Discussion

The Intervenors message stood out to general audience participants with good examples presented in a concise manner. Participants felt the Intervenors message was credible and the death statistics were new information for them.

Some participants felt the S>M/NCI 2010 message condensed the more striking points into a shorter, more easily absorbed message. What they liked about the S>M/NCI 2010 message was its brevity and directness.

Participants often mentioned information about pregnant women and children aloud, which may indicate that it stood out to them from the other information included.

7 Note that the first two focus groups (current smokers, low SES and never/former smokers) did the ranking exercise collectively and arrived at a group consensus, whereas subsequent groups did the ranking exercise individually. This change was made to shorten the exercise length and ensure all discussion topics could be covered in the allotted time for the focus groups.

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“…This one is giving you things that you can directly relate it to like more people die from smoking than murder, AIDS, suicide, drugs, car crashes, and alcohol combined.” [About the Intervenors statement]

Scare tactics were perceived in the messages that listed the harms of smoking at length. General audience participants felt that the Lorillard message was too long. They did not take much away from reading the BATCo message other than needing to find the information yourself and some participants said it did not grab their attention.

Importantly, the word “causal”—used most frequently in the Lorillard statement—was often read as “casual” by a number of participants and may cause some confusion for audiences.

“And there’s a casual relationship, so it’s saying smoking is kind of related to all of this stuff …”

Hispanic participants most valued statements that offered up new information. Feeling that they learned more about the death toll caused by cigarettes from the Intervenors and S>M/NCI 2010 statements, they rejected the Philip Morris and RJ Reynolds statements for not offering any new information.

The Intervenors statement initiated more conversation about death statistics than did the Lorillard statement.

“I was more shocked by the fact that there’re more deaths related to smoking than murders and suicides. I didn’t know that.”[Hispanic respondent, about the Intervenors statement]

Also, the BATCo statement was widely regarded, in this and in other topics, to be void of any direct information. Participants in all groups felt the main message of most of the BATCo statements to be: “If you want to know something, go and find out yourself.”

In the teen groups, the information that stood out the most was “smoking kills 1,200 Americans each day,” in the S>M/NCI 2010 statement. The fact about death statistics in the Intervenors statement was striking as well. One comment participants made about the statements differentiated between consequences and statistics. While potential consequences conveyed possibilities, they felt, statistics were less likely to be ignored because they were more factual.

Teen participants ranked the BATCo and RJ Reynolds statements as the least clear and impacting message while the Intervenors were at the top of the rankings. They liked the statistical information included in the Intervenors statement. Participants in the teen groups found the Lorillard statement too long, likening it to school-related reading.

“I don’t think some of the ones that list all the consequences and these people are just going to look as possibilities but when they say that the statistics and facts of how many people die and how the dangers of it compared to other diseases and stuff like that, that you can’t ignore that.” [Teen respondent]

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Corrective Topic B: The addictiveness of smoking and nicotine Recommendations As in the previous topic, the statements submitted by BATCo. were felt to be the least effective at relaying this area of information, so they were excluded from the next round of research for this topic.

Despite close rankings, we recommended excluding the RJ Reynolds statement and keeping the Philip Morris statement for the same reasons cited for the ‘Adverse Health Effects’ topic area.

Rankings 1st 2nd 3rd 4th 5th 6th Summary of 5th/6th BATCo 6 1 5 6 2 28 30 Philip Morris 1 4 12 10 19 2 21 RJ Reynolds 1 5 6 17 14 5 19 Lorillard 2 10 13 7 8 8 16 Intervenors 33 6 4 3 1 1 2 S>M/NCI 2010 5 22 8 5 4 4 8 Detailed Discussion General audience participants had mixed responses about learning something new from this set of statements. Some participants reported learning that it can take more than will power to quit smoking while other participants reported already knowing that. They responded positively to the admission of manipulation and lying from cigarette manufacturers. There was a feeling in some participants that the Intervenors statement might not stop smokers from smoking but might make smoking unattractive for non-smokers. Most participants felt the BATCo statement did not offer any new or interesting information about the addictiveness of nicotine and tobacco. Other statements, like the one offered by Lorillard, offered information that is already widely available to and known by the public.

“It doesn’t have any shock factor for me. I mean I already felt that way from when I came in the door.” [About the Lorillard statement]

“It tells you that it’s hard to quit, that it’s addictive and that it affects your brain.” [About why they chose Intervenors statement as the top in this group]

In general, the corrective statements in this topic area seemed to spark feelings of guilt in some participants who were smokers and made some smokers feel defensive. A few participants stated that the Philip Morris statement made them not want to attempt to quit smoking because the statement said it was very difficult to do so.

Participants in the Hispanic focus groups felt that this corrective topic was generally the same message they’ve always heard about the addictiveness of cigarettes, noting that they’ve seen the Surgeon General say this before.

The BATCo statement did not resonate with participants, who ranked below all other statements, because it did not offer any new or striking information or impact. They liked that the Intervenors

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statement framed the message as a retraction from the cigarette manufacturers regarding the definite addictiveness of cigarettes, saying it gave the statement more credibility.

“I don’t think it’d have such a strong impact because all this information is like, you could say it’s not the first time you hear this. Smoking is addictive, we all know that. They manipulate it to be addictive, we all know that. It’s different to see it in black and white, but it won’t cause an impact.” [Hispanic respondent, during dialogue about the Intervenors statement, but about all the statements in this topic area more generally.]

Participants in the teen focus groups generally understood that the main idea of this corrective topic was the addictiveness of nicotine. Adding the source of information (cigarette manufacturer), they said, made the statement more reliable. The BATCo statement was ranked at the bottom because, participants said, it’s the same message they’re already hearing. The Intervenors statement was ranked at the top in the non-smokers group while Lorillard and S>M/NCI 2010 were ranked at the top in the smokers group.

“This gets preached every five seconds.” [Teen, about the BATCo statement]

New information for teen participants that was included in this topic was that nicotine changes the brain.

While teen smokers stated that this information would not make them want to quit smoking, they also said that it did not make them give up hope of ever quitting tobacco.

General audience participants understood the underlying message of these statements, which was that cigarettes cause the same amount of damage regardless of style. There was nothing reported as confusing in any of these messages.

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Some participants liked the Intervenors message because it mentioned the manufacturer, saying it lent a feeling of honesty to the statement. For others, the S>M/NCI 2010 message resonated because of its simplicity and because they felt it was straightforward. Some participants chose the S>M/NCI 2010 message as the top statement because it was concise and direct. They also responded strongly to the “truth” language in the S>M/NCI 2010 statement. Still others preferred the language starting with “We falsely marketed…” in the Intervenors statement. This direct admission to misleading the public generated the strongest negative feelings toward cigarette manufacturers of any statement in this topic area.

The BATCo statement was considered the most clear in one general audience group for explicitly stating the corrective topic matter. Some participants preferred the Philip Morris statement, feeling it was the most direct.

“I knew cigarettes weren’t good for you, but I figured that they [‘low tar,’ ‘light,’ etc.] were a little bit healthier for you and maybe the tobacco was a little bit healthier for you.” [About learning something new]

In the Hispanic focus groups, this corrective topic offered much new information as many participants reported being unaware that all cigarettes cause the same amount of damage to a person’s health regardless of the style. The main idea of all the statements in this topic was taken to mean that “there is no cigarette that won’t kill you.” The overall message the statements conveyed was that smokers can smoke any kind of cigarette – regular versus light or cheap versus expensive – because “it’s all the same.”

“This [the statement] has been done under order by the District Court, done by the cigarette company itself and in it they are saying “we falsely market these cigarettes.”

Just with that they are telling us, it’s all a scam. There’s no difference at all. When they say light, medium, low, it’s all the same with a different package. That’s what they’re saying in a few words. It’s coming from their own mouth. When they do marketing they get to say lies, here they have to tell the truth by federal order.” [Hispanic respondent]

Teen participants felt that the corrective statement that all cigarettes cause the same amount of harm was clearly conveyed in all of the messages. Participants reportedly learned new information about how all cigarettes cause the same harm regardless of its style. The Intervenors statement was set apart by presenting facts in bullet form and that cigarette manufacturers were admitting they were wrong to market some types of cigarettes as less harmful. Some participants liked the S>M/NCI 2010 statement for its directness and the Philip Morris statement for its simplicity. RJ Reynolds, Lorillard and BATCo were ranked at the bottom.

The difference some participants in these teen groups—both smokers and non-smokers—felt this topic might make is that smokers may stop buying light cigarettes and smoke regular cigarettes instead.

Smokers felt, however that it would not make a difference in their decision whether to smoke in the first place.

“I like the part of [the Intervenors statement] how they’re admitting they were falsely advertising that the cigarettes were light so they didn’t have as much nicotine or tar in them. That’s why I placed [it] up top for me. So, if they’d put like that junk on [the Philip Morris statement], it’d make a difference for me.” [Teen]

The statements submitted by BATCo. were felt to be the least effective at relaying this area of information, so they were excluded from the next round of research for this topic.

Despite close rankings, we recommended excluding the Lorillard statement and keeping the Philip Morris statement for the same reasons cited for the ‘Adverse Health Effects’ and ‘Addictive’ topic areas.

Rankings 1st 2nd 3rd 4th 5th 6th

Summary of

5th/6th

BATCo 2 3 6 8 16 13 29

Philip Morris 2 5 10 9 8 14 22

RJ Reynolds 2 11 6 10 3 16 19

Lorillard 2 1 11 14 17 3 20

Intervenors 35 3 6 3 0 1 1

S>M/NCI 2010 5 25 9 4 4 1 5

Detailed Discussion

Many participants responded strongly to the word “manipulate” in terms of feeling they were deceived.

The majority of participants felt that the Intervenors statement communicated this topic most clearly while being specific but clear.

“I think they made a very good point that when things are bulleted that you read them— it’s much easier on the eyes. You read each one separately.” [About the Intervenors statement]

Hispanic participants similarly felt that the Intervenors’ statement best described the intent of this corrective topic. They indicated that the bullets made each point clear and the “court ordered” language lent the statement credibility.

The term and definition for “tar” in Spanish was discussed in some detail. Different terms are used in different countries of origin. There was also some confusion over what exactly what being manipulated.

Some participants in these groups felt the messages were informing the audience about how cigarette companies manipulate the customers into buying more cigarettes while others felt the messages were talking about the levels of nicotine. Although some participants did understand that the levels of nicotine were being manipulated, they did not agree about what that meant.

[The dialogue below occurred when Hispanic participants were asked to state the main idea of the BATCo statement.]

P1: “Manipulating the design to market to children.”

P2: “Manufacturers manipulating people.”

P3: “The way they induce people to buy cigarettes.”

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Teen participants felt the Intervenors statement was the easiest to understand while other statements did not deliver the message clearly. Some participants felt the Intervenors statement could be improved if it were shorter. The federal court order language made this statement more believable.

“[The Intervenors statement] tells you exactly what they’re doing as in manipulating the chemicals inside to make it more addicting. And it puts it in a plain manner instead of selling straight facts like it came from a computer.” [Teen respondent]

Some general audience participants felt that this topic contained little new information while others felt the number of chemicals found in secondhand smoke was something new. Again, information about harm to children seemed to start dialogue in some groups.

The Intervenors message was ranked at the top because messages about “the truth” and information about the number of chemicals resonated with participants. Some participants chose the S>M/NCI 2010 as the top message because of the death statistics it included, although a few participants felt the 38,000 figure was low compared with their expectations.

Some participants felt that the S>M/NCI 2010 statement summarized the important points better than the Intervenors statement because it was a shorter read while still including all the pertinent information.

Participants felt the S>M/NCI 2010 message might make non-smokers more aware of their surroundings and the environments they take their children. Participants felt the Lorillard message was too lengthy to keep audience members’ attention, saying it read like a pharmaceutical advertisement listing the side effects of a drug.

“Being more conscious, if you are a smoker, who you smoke around. And if you’re not, keeping your kids away from people who smoke or places where there might be smoke.

Make it safer.”[About the effects of the Intervenors statement]

“The part that made the least impact to me was you should rely upon your medical provider and the Surgeon General making decisions regarding smoking. That had the

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least impact. I like the here’s the truth, hey these guys made us tell you.”[Respondent comparing statements from cigarette manufacturers to Intervenors and SM/NCI]

Participants in the Hispanic groups felt the Intervenors’ message was the most shocking as it conveyed that cigarettes contain a large number (4,800) of chemicals, although, one participant noted that this message was already being sent through television. They also chose this statement because it showed that smoking affects the non-smoker’s health as well as the smoker’s. The added information about the court order seemed to again help the credibility of this statement.

“It’s something different because it says not only the harm you’re doing to yourself. It already says that, but the harm you’re doing to others.” [Hispanic respondent, about the Intervenors statement]

The BATCo statement caused some confusion with the ETS (HTA in Spanish) abbreviation. Participants also felt that this statement was more about finding information than secondhand smoke.

Some participants in the Hispanic groups said that the Philip Morris statement did contain some new information, specifically that secondhand smoke causes illness. They reported that this was important information that the public should be made aware of.

“And most of all, it causes the same kind of damage for kids as if it was an adult who was smoking.” [Hispanic respondent, about the Philip Morris statement]

For the RJ Reynolds statement, participants focused on the information about children. Participants felt the Lorillard statement cautioned the smoker against smoking near non-smokers. Participants in these groups felt that the Intervenors’ statement focused on the chemicals cigarettes contain. The S>M/NCI 2010 statement touched on the point that cigarette manufacturers are admitting to the effects of secondhand smoke.

Teen smokers noted aloud that pregnant women and children were harmed by secondhand smoke.

This seemed to jump out at participants. The fact that cigarette smoke contains many chemicals also resonated with them.

Teens placed BATCo at the bottom of the list based on a combination of its brevity, lack of clarity and inability to attract their attention. The RJ Reynolds, Philip Morris and Intervenors statements were ranked at the top of the list. Statements that included facts and examples and were direct and easy to understand seemed to resonate well with teen participants.

“It gives examples of each thing like, the chemicals it contains and what it does to you and how even second hand smoke affects others.” [Teen, about why the Intervenors statement was chosen as the statement that most clearly communicates the message]

APPENDIX D1: Phase I Focus Group Written Report

D1-20

Audience Testing for Tobacco- Related Corrective Statements

Recruitment Screener

November 2010

Name of Participant:

_________________________

Name of Recruiter:

_________________________

Date Contacted:

_________________________

Date of Confirmation Call:

_________________________

Group # _________

Date/Time:

___________________

APPENDIX D2: English Focus Group Screener

D2-1

8 Groups in total (recruit 10 for 8 to show), broken out as follows:

Maryland Groups Florida Groups

1=Current smokers: mix of ethnicities,

approximates diversity of current population of

smokers

1=Current smokers: Hispanic (in Spanish)

1=Current smokers: low SES, mix of

ethnicities

1=Non-smokers (3) and former smokers (7):

Hispanic (in Spanish)

1=Non-smokers (3) and former smokers (7):

mix of ethnicities

1= Young adult smokers: 18-21 year olds

1=Non-smokers (3) and former smokers (7):

low SES, mix of ethnicities

1= Young adult non-smokers: 18-21 year olds

Recruitment Script:

Good morning/afternoon/evening, my name is __________ and I’m calling from ________

(name of company). We’re conducting research in (insert market). I am not selling anything nor will you be asked to sign up for or purchase anything. We are looking for individuals to participate in a discussion group about health issues in (insert market). Participants will be offered an incentive of $XX.

1. Does this sound like something you’d be interested in doing?

a) No >>> [THANK AND TERMINATE]

b) Yes >>> [CONTINUE]

Thank you. First, we want to make sure we get a variety of people for our groups so I need to ask you a few questions about yourself.

This question is intended to establish whether the respondent is reasonably articulate and audible, and willing to converse. If respondent has a serious speech impediment or has trouble communicating (e.g., “shuts down”), THANK AND TERMINATE.

INVITE TO PARTICIPATE

Thank you for answering my questions. I would like to tell you a little more about the discussion group. The group will meet on [Date] at [Time] at our facility in [Location]. [Give address].

You will join up to 7 other people and a moderator. It will meet for about an hour and a half. You will receive $XX for coming.

So that we can start and end on time, please come about 15 minutes early to pick up your nametag and to have some snacks. Will you please contact us as soon as possible if something comes up and you can’t come? (Give phone number).

APPENDIX D2: English Focus Group Screener D2-5 Before we hang up, let me get the correct spelling of your name and your address and phone numbers so we can send you a letter with directions and give you a reminder call the day of the group.

NAME______________________________

HOME PHONE/CELL PHONE______________________

ADDRESS____________________________________________

E-MAIL______________________

Thanks again for your time and we’ll see you at the group!

APPENDIX D2: English Focus Group Screener D2-6 Identification of Project Message Development and Testing

Statement of Age of Subject I state that I am at least 18 years of age, in good physical health, and wish to participate in a program of research being conducted by Salter>Mitchell in the offices of Baltimore Research:

_________________________.

Purpose The purpose of this research is to evaluate a series of statements that may eventually turn into materials seen on TV, newspaper, online, or in stores.

Procedures Participants will be asked to review, rank and discuss a series of written statements. They will be asked to discuss how clearly they communicated different ideas and why they feel that way.

The total time involved, including instructions will be no more than 90 minutes.

Confidentiality All information collected in this study will be kept secure to the extent permitted by law. I understand that the data I provide will be grouped with data others provide for the purpose of reporting and presentation and that my name will not be used. I understand that the focus group will be audiotaped for analysis purposes, and a live video of the focus group will be broadcast in real-time to remote members of the research team who could not be here in person.

However, the video of the group WILL NOT be recorded and your voice will not be played to others besides the research team without my written permission.

Risks I understand that the risks of my participation are expected to be minimal in nature.

Benefits, Freedom to Withdraw, & Ability to Ask Questions

I understand that this study is not designed to help me personally but that the investigators hope to use the research findings in order to develop communications that may benefits people more broadly, myself included. I am free to ask questions or withdraw from participation at any time and without penalty.

Contact Information of Investigators Name: Kelly Blake, Sc.D.

Telephone: (301) 402-8425

Printed Name of Research Participant _____________________________

Signature of Research Participant ________________________________

Date______________________

APPENDIX D3: Phase I English Focus Group Consent and Assent Forms D3-1 ASSENT/CONSENT FORM

I, the parent or legal guardian of ________________, have read the previous pages of the consent form and the investigator has explained the details of the study. I understand that I am free to ask additional questions.

I understand that participation in this study is voluntary and my child may refuse to participate or may discontinue participation at any time without penalty, loss of benefits, or prejudice.

_______________________________________ __________________________

PARENT OR LEGAL GUARDIAN (subject is a minor) DATE

The subject has been given the opportunity to read a description of the protocol, to ask questions before signing, and has been given a copy.

_________________________________ ___________________________

PRINT INVESTIGATOR’S NAME AND DATE SIGNATURE OF INVESTIGATOR

For any questions regarding the rights of a research subject, or information regarding treatment of research-related injuries, please contact the Investigator:

• Hi, my name is ____________ and I’ll be leading this discussion today. We’re having this discussion group to ask you what you think about a few topics. We really want to hear your opinions.

• What we’re doing here today is called a focus group. It’s a way for researchers to hear your thoughts and ideas. I’m not an expert in anything that we’ll be talking about today.

I’m only here to ask questions and listen to what you have to say. I want to hear everything you have to say, both positive and negative.

• There are no right or wrong answers, and it’s really important that I hear what everyone thinks, so please don’t be afraid to speak up, even if you disagree with what someone else says.

• Our talk today will be audiotaped so that we can hear what everyone says. We’ll use the tapes to write a report about what was said. The report will not include your name. There are also colleagues of mine observing here and at their computers on a passwordprotected live video feed. This is also to help take notes and write the report. You are not being videotaped.

• This is a group discussion so please don’t wait for me to call on you. There’s no need to raise your hand, but please speak one at a time so the tape recorder can pick up all of your comments.

• I have a lot of questions and a very limited amount of time, so at times I may change the subject or move ahead. I’ll come back to earlier points if there’s time.

• Please turn off mobile phone and pagers. We would like you to relax, ask that everyone participate in the discussions, and invite you to have an open and free dialogue.

• Does anyone have any questions?

• Let’s start off with introductions – what’s your first name and what you like to do in your spare time?

2. Warm-Up: Background on Smoking Communications (1 Mins)

• We’re going to be looking at some communications related to smoking and tobacco today.

• But don’t worry – if you smoke, we’re not going to try to talk you out of it. And if you don’t smoke, we’re not going to try to talk you into it. We’re smoking-neutral.

• What we are going to do is show you some statements that talk about smoking and ask

APPENDIX D4: English Focus Group Moderator Guide D4-1 you what they communicate to you… how clearly they say things… whether they’re believable … what impact they have on you…things like that.

3. Corrective statement evaluations – 75 minutes (15 per each of the 5 corrective areas) So here’s what we’re going to do…

• I’m going to give you a card that has a statement on it. I’d like you to read it, and then we’re going to briefly discuss it. Then we’re going to do the same thing with another card and so on until you have 6 cards.

Since we have a lot to get through, I’ll tell you ahead of time what question I want to discuss: THIS WILL BE ON THE EASEL BOARD

• I want you to complete this sentence: The main idea of the statement is______________.

• Now you have 6 different statements in front of you. These statements are designed to communicate {list corrective area}. What I want you to do is work as a group to rank them from 1 to 6 based on these criteria: PUT ON EASEL BOARD SEE ATTACHED EXERCISE CARD SHEET FOR FULL LIST OF RANKING EXERCISES AND STATEMENTS

Now, to clarify, when I say MOST CLEARLY COMMUNICATES, I want you to again imagine that you were to see this statement in a newspaper, TV, online, or in a store, and I want you to take into account…

• How easy is it to understand?

• Whether you would pay attention to it?

• And whether you think it would have any lasting impact on you?

GIVE GROUP 4 MINUTES TO COMPLETE THIS TASK. ENCOURAGE THEM TO TALK ALOUD WHILE THEY DO IT.

ONCE DONE, RECORD ORDER OF FINAL RANKING ON EASEL BOARD.

• Is the top ranked statement a clear winner or was it a close call? What about the bottom statements?

FOCUS ON TOP STATEMENT FOR REMAINING QUESTIONS.

• Why did you say that this statement does the best job communicating___________________?

APPENDIX D4: English Focus Group Moderator Guide D4-2 • If you were to later hear an opposite claim (refuting the corrective statement) would you be likely to believe it? Why do you say that?

• What impact do you think this would have on other people’s behavior? Do you think it will change anything? If so, what and why?

o Does it have any impact on your attitudes toward smoking?

o Would the statement make you more or less likely to begin smoking/quit smoking? Or would it have no impact either way? Why?

For smoker groups when discussing B statements: Does this make you give up hope of ever quitting?

• Do you find anything about this statement confusing or hard to understand? How would you improve it?

o Is it too long or too short?

• Did you believe the information in the statement? Why or why not?

• Did you learn something new? If so, what?

WE’LL DO THIS FOR EACH OF THE 5 STATEMENT TOPICS AND DO A REVIEW OF THE TOP 5 OVERALL AT THE END.

4. Context/Attribution of Statements (10 minutes) Note: While some of the below is likely to have come up earlier, use this time to circle back and clarify on the below questions.

• Some of the statements we saw had details like who was making the statements and why they were doing it, while others didn’t.

o Did that extra information have any impact on your impressions of the statements?

o If that kind of information were included along with the statements, would it impact whether the statement would get your attention? Why or why not?

o Does this kind of information impact the trustworthiness of the statement? Why or why not?

• Does it matter if you’re familiar with the company who’s making these statements?

o Probe for awareness of: Philip Morris, RJ Reynolds, Lorillard and British American Tobacco, Altria and discuss whether there would be any difference in impact of statements depending on which was included.

The corrective statements below were tested and randomized for each of the general audience and teen focus groups. The two tables below serve as a legend for labeling the statements. The letter represents the corrective area the statement is testing while the number represents the source of that message.

Participants were not aware of the source of the message. They were, however, aware of which corrective area the messages addressed.

There are adverse health effects from cigarette smoking. For a list of health effects from smoking and a discussion of the relevant science, see the 2004 Report of the Surgeon General “The Health Consequences of Smoking.”

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is taken from the 2004 Surgeon General’s Report.

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

A-4.

The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) (Order #1015, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal).

The Surgeon General has concluded that the evidence is sufficient to infer a causal relationship between cigarette smoking and the following:

Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but this should not deter smokers who want to quit from trying to do so.

B-3.

The Surgeon General has concluded:

• Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction.

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is taken from the 1988 Surgeon General’s Report.

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

B-4.

The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) (Order #1015, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal).

The Surgeon General has concluded:

• Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction.

These conclusions are contained in the 1988 Surgeon General’s Report. [Cigarette Manufacturer Name]

encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

B-5.

We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and all it takes to quit is willpower.

Here’s the truth:

• Smoking is very addictive. And it’s not easy to quit.

• We manipulated cigarettes to make them more addictive.

• When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District Court.

B-6.

A federal court is requiring tobacco companies to tell the truth about smoking. Here’s the truth:

• Cigarettes deliver doses of nicotine that create and sustain addiction, which means smoking gets very, very hard to quit.

• The result: People keep buying cigarettes long after they wish they had quit.

There is no safe cigarette. “Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception.

You should not assume that these brands are safe or safer than full flavor brands or that smoking these brands will help you quit. If you are concerned about the health risks of smoking, you should quit.

C-3.

The Surgeon General has concluded:

• Smoking cigarettes with lower machine-measured yields of tar and nicotine (including those that have been labeled “low tar,” “light,” “ultra light, “mild” and “natural”) provides no clear benefit to health in comparison to smoking cigarettes with higher machine-measured yields of tar and nicotine.

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is derived from the 2004 Surgeon General’s Report.

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

C-4.

The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) (Order #1015, Aug. 17, 2006, at 4; Final Op. at 1636-
37) (on appeal).

The Surgeon General has concluded:

• Smoking cigarettes with lower machine-measured yields of tar and nicotine (including those that have been labeled “low tar,” “light,” “ultra light, “mild” and “natural”) provides no clear benefit to health in comparison to smoking cigarettes with higher machine-measured yields of tar and nicotine.

This conclusion is contained in the 2004 Surgeon General’s Report. [Cigarette Manufacturer Name]

encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

C-5.

We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sustain our profits.

We knew that many smokers switch to low tar and light cigarettes rather than quitting because they believe low tar and lights are less harmful. They are NOT.

Here’s the truth:

• Just because lights and low-tar cigarettes feel smoother, that doesn’t mean they are any better for you. Light cigarettes can deliver the same amounts of tar and nicotine as regular cigarettes.

[Cigarette Manufacturer Name] manipulates the design of its cigarette brands to ensure that every cigarette of a particular brand or style will deliver the amount of nicotine (within 0.1 mg.) advertised for that brand, according to the test for nicotine in cigarette smoke adopted by the International Standards Organization.

D-2.

Cigarettes deliver tar and nicotine. Well known design features affect the delivery of tar and nicotine.

The amount of tar and nicotine you inhale will vary, depending upon how you smoke. Generally speaking, the more intensely you smoke a cigarette, the more tar and nicotine you will inhale.

D-3.

A United States District Court has found that:

• “Cigarettes are specifically designed to deliver a range of nicotine doses so that a smoker can obtain her optimal dose from virtually any cigarette on the market, regardless of that cigarette’s nicotine delivery level as measured by the FTC method.”

• “Cigarette manufacturers controlled the amount and form of nicotine delivery in commercial products by controlling the physical and chemical make-up of the tobacco blend and filler.”

This message is furnished pursuant to a Court Order by [Cigarette Manufacturer Name].

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

D-4.

The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) (Order #1015, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal).

• Cigarette manufacturers “controlled the amount and form of nicotine delivery in their commercial products by controlling the physical and chemical make-up of the tobacco blend and filter.”

D-5.

For decades, we denied that we controlled the level of nicotine delivered in cigarettes.

Here’s the truth:

• Cigarettes are a finely-tuned nicotine delivery device designed to addict people.

• We control nicotine delivery to create and sustain smokers’ addiction, because that’s how we keep customers coming back.

• We also add chemicals, such as ammonia, to enhance the impact of nicotine and make cigarettes taste less harsh.

• When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District Court.

D-6.

A federal court is requiring tobacco companies to tell the truth about smoking. Here’s the truth:

• Tobacco companies manipulate the nicotine levels in cigarettes. So nicotine is delivered in doses that create and sustain addiction.

APPENDIX D5: English Focus Group Flashcards

D5-6

7

• The result: People keep buying cigarettes long after they wish they had quit.

Topic E: The adverse health effects of exposure to secondhand smoke.

E-1.

There are adverse health effects from exposure to second hand smoke (also known as environmental tobacco smoke or ETS). For a list of health effects and a discussion of the relevant science, see the 2006 Report of the Surgeon General “The Health Consequences of Involuntary Exposure to Tobacco Smoke.” E-2.

Public health officials have concluded that secondhand smoke from cigarettes causes disease, including lung cancer and heart disease, in non-smoking adults, as well as causes conditions in children such as asthma, respiratory infections, cough, wheeze, otitis media (middle ear infection) and Sudden Infant Death Syndrome.

E-3.

The Surgeon General has concluded:

• Exposure to environmental tobacco smoke has been proven to cause premature death and disease in children and in adults who do not smoke. Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is taken from the 2006 Surgeon General’s Report.

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

E-4.

The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States of America, Civil Action No. 99-2496 (GK) (Order #1015, Aug. 17, 2006, at 4; Final Op. at 1636) (on appeal).

The Surgeon General has concluded:

• The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and sudden infant death syndrome; and a lower level of lung function during childhood.

• The evidence is sufficient to infer a causal relationship between maternal exposure to secondhand smoke during pregnancy and a small reduction in birth weight; and persistent adverse effects on lung function across childhood. The evidence is sufficient to infer a causal relationship between secondhand smoke exposure from parental smoking and lower respiratory illnesses in infants and children; middle ear disease in children, including acute and recurrent otitis media and chronic middle ear effusion; cough, phlegm, wheeze, breathlessness and ever having asthma among children of school age; and the onset of wheeze illnesses in early childhood.

• The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and lung cancer among lifetime nonsmokers; increased risks of coronary heart disease morbidity and mortality among both men and women; odor annoyance; nasal irritation; atherosclerosis in

• Secondhand smoke has been proven to cause lung cancer and heart attacks and kills over 38,000 Americans each year.

• There is no risk-free exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

Paid for by [Cigarette Manufacturer Name] under order of a Federal District Court.

E-6.

A federal court is requiring tobacco companies to tell the truth about smoking. Here’s the truth:

• Secondhand smoke kills 38,000 Americans every year.

• Children exposed to cigarette smoke suffer more from asthma, pneumonia, bronchitis and ear infections. Adults exposed also suffer because they inhale the same chemicals from secondhand smoke that kill and disable smokers.

APPENDIX B: Corrective Statements Tested in Qualitative (Spanish) All translations into Spanish of research material were conducted by staff from Salter>Mitchell or recruiting field facilities.

The corrective statements below were tested and randomized for each Spanish-language focus group.

The two tables below serve as a legend for labeling the statements. The letter represents the corrective area the statement is testing while the number represents the source of that message. Participants were not aware of the source of the message. They were, however, aware of which corrective area the messages addressed.

1. Current smokers above the 200% federal poverty level aged 18 and over

2. Current smokers at or below the 200% federal poverty level aged 18 and over

3. Former or non-smokers above the 200% federal poverty level aged 18 and over

4. Former or non-smokers at or below the 200% federal poverty level aged 18 and over

5. African Americans aged 18 and over

6. Predominantly Spanish speaking Hispanics aged 18 and over

7. Teenagers aged 14 to 17 All adult respondents must have provided their consent before proceeding to the rest of the survey. For the teenage sample, parents were asked to provide consent for their teens to be interviewed and the teens also provided their assent to participate in the survey.

To sample the population, Knowledge Networks sampled households from its KnowledgePanel, a probability-based web panel designed to be representative of the United States. Knowledge Networks used its profiling information to determine one’s federal poverty level, smoking status, race/ethnicity, language proficiency, and availability of teenager aged 14 to 17 in the household.

Data Collection Field Period & Survey Length The data collection field periods were as follows Stage Start Date End Date Pretest 12/23/2010 12/27/2010 Main 12/31/2010 1/10/2010 Participants completed the main survey in 20 minutes (median).

APPENDIX E1: Knowledge Networks Project Report E1-4 5 Survey Completion and Sample Sizes The number of respondents sampled and participating in the survey, the survey completion rates, and the consent rates are presented below.

• Demographic profile data for all interviewed KN panelists Several supplemental variables are provided to assist the principal investigators in identifying cases that could potentially be of interest.

The Strata variable was created for use by SUDAAN for variance estimation. We replicate, as closely as possible, the implicit stratification used by MSG (the RDD sample frame vendor) in selecting RDD samples to create this variable. We sort all numbers in the sample by region (9 categories), urban/rural, county, area code, and telephone exchange. We then collapse neighboring exchanges so that there are at last five exchanges in each stratum.

The table below shows the name and description of each of the supplemental, demographic, and other profile variables delivered to the client.

APPENDIX E1: Knowledge Networks Project Report E1-8 9 Knowledge Networks Methodology Introduction Knowledge Networks (KN) has recruited the first online research panel that is representative of the entire U.S. population. Panel members are randomly recruited through probability-based sampling, and households are provided with access to the Internet and hardware if needed.

Knowledge Networks selects households by using address-based sampling methods; formerly, KN relied on random-digit dialing (RDD) Once households are recruited for the panel, they are contacted by e-mail for survey taking or panelists visit their online member page for survey taking (instead of being contacted by phone or postal mail). This allows surveys to be fielded very quickly and economically. In addition, this approach reduces the burden placed on respondents, since e-mail notification is less intrusive than telephone calls, and most respondents find answering Web questionnaires more interesting and engaging than being questioned by a telephone interviewer. Furthermore, respondents have the freedom to choose what time of day to participate in research.

• www.knowledgenetworks.com… Panel Recruitment Methodology When Knowledge Networks began recruiting in 1999, the company established the first online research panel (now called KnowledgePanel®) based on probability sampling covering both the online and offline populations in the U.S. Panel members are recruited through national random samples, originally by telephone and now almost entirely by postal mail. Households are provided with access to the Internet and hardware if needed. Unlike Internet convenience panels, also known as “opt-in” panels, that includes only individuals with Internet access who volunteer themselves for research, KnowledgePanel recruitment uses dual sampling frames that includes both listed and unlisted telephone numbers, telephone and non-telephone households, and cellphone- only households, as well as households with and without Internet access. Only persons sampled through these probability-based techniques are eligible to participate on KnowledgePanel. Unless invited to do so as part of these national samples, no one on their own can volunteer to be on the panel.

APPENDIX E1: Knowledge Networks Project Report E1-9 10 RDD and ABS Sample Frames KnowledgePanel members today could have been recruited by either the former random digit dialing (RDD) sampling or the current address-based sampling (ABS) methodologies In this section, we will describe the RDD-based methodology; the ABS methodology is described in a separate section below. To offset attrition, multiple recruitment samples are fielded evenly throughout the calendar year.

KnowledgePanel recruitment methodology has used the quality standards established by selected RDD surveys conducted for the Federal government (such as the CDC-sponsored National Immunization Survey).

KN employed list-assisted RDD sampling techniques based on a sample frame of the U.S.

residential landline telephone universe. For purposes of efficiency, KN excludes only those banks of telephone numbers (a bank consists of 100 numbers) that had fewer than two directory listings. Additionally, an oversampling was conducted within a stratum of telephone exchanges that had high concentrations of African American and Hispanic households based on Census data. Note that recruitment sampling is done without replacement, thus numbers already fielded do not get fielded again.

A telephone number for which a valid postal address can be matched occurred in about 67-70% of each sample. These address-matched cases were all mailed an advance letter informing them that they had been selected to participate in KnowledgePanel. For purposes of efficiency, the unmatched numbers were most recently under-sampled at a rate of 0.75 relative to the matched numbers. Both the minority oversampling mentioned above and this under-sampling of nonaddress households are adjusted appropriately in the panel’s weighting procedures.

Following the mailings, telephone recruitment by trained interviewers/recruiters begins for all sampled telephone numbers. Telephone numbers for cases sent to recruiters were dialed for up to 90 days, with at least 14 dial attempts for cases in which no one answers the phone, and for numbers known to be associated with households. Extensive refusal conversion was also performed. The recruitment interview, about 10 minutes in length, begins with informing the household member that the household had been selected to join KnowledgePanel. If the household does not have a computer and access to the Internet, the household member is told that in return for completing a short survey weekly, the household will be provided with free monthly Internet access and a laptop computer (in the past, the household was provided with a WebTV device). All members of the household are enumerated, and some initial demographic and background information on prior computer and Internet use was collected.

Households that informed recruiters that they had a home computer and Internet access were asked to take KN surveys using their own equipment and Internet connection. Incentive points per survey, redeemable for cash, are given to these “PC” (personal computer) respondents for completing their surveys. Panel members provided with a laptop computer and free Internet access do not participate in this per-survey points-incentive program. However, all panel members do receive special incentive points for select surveys to improve response rates and/or

APPENDIX E1: Knowledge Networks Project Report E1-10 11 for all longer surveys as a modest compensation for the extra burden of their time and participation.

For those panel members receiving a laptop computer, each unit is custom-configured prior to shipment with individual email accounts so that it is ready for immediate use by the household.

Most households are able to install the hardware without additional assistance, although KN maintains a toll-free telephone line for technical support. The KN Call Center contacts household members who do not respond to e-mail and attempts to restore both contact and participation.

PC panel members provide their own e-mail addresses, and we send their weekly survey invitations to that e-mail account.

All new panel members receive an initial survey for the dual purpose of welcoming them as new panel members and introducing them to how online survey questionnaires work. New panel members also complete a separate profile survey that collects essential demographic information such as gender, age, race, income, and education to create a personal member profile. This information can be used to determine eligibility for specific studies and is factored in for weighting purposes. Operationally, once the profile information is stored, it does not need to be re-collected as a part of each and every survey. This information is also updated annually for all panel members. Once new members have completed their profile surveys, they are designated as “active,” and considered ready to be sampled for client studies. [Note: Parental or legal guardian consent is also collected for the purpose of conducting surveys with teenage panel members, aged 13 to17.]

Once a household is recruited and each household member’s e-mail address is either obtained or provided, panel members are sent survey invitations linked through a personalized e-mail message (instead of by phone or postal mail). This contact method permits surveys to be fielded quickly and economically, and also facilitates longitudinal research. In addition, this approach reduces the burden placed on respondents, since e-mail notification is less intrusive than telephone calls and allows research subjects to participate in research when it is convenient for them.

Address-Based Sampling (ABS) Methodology When KN first started panel recruitment in 1999, the conventional opinion among survey experts was that probability-based sampling could be carried out cost effectively through the use of a national RDD samples. The RDD landline frame at the time allowed access to 96% of U.S.

households. This is no longer the case. In 2009, Knowledge Networks introduced use of the ABS sample frame to panel recruitment to reflect the real changes in society and telephony over recent years. Those changes that have reduced the long-term scientific viability of landline RDD sampling methodology are as follows: declining respondent cooperation in telephone surveys as reflected in “do not call” lists, call screening, caller-ID devices, and answering machines;

dilution of the RDD sample frame as measured by the working telephone number rate; and

finally, the emergence of cell phone-only households (CPOHH) because such households are excluded from the RDD frame because they have no landline telephone.

APPENDIX E1: Knowledge Networks Project Report E1-11 12 According to the Centers for Disease Control and Prevention (January-June 2010), approximately 28.6% of all U.S. households cannot be contacted through RDD sampling—
26.6% as a result of CPOHH status and 2% because they have no telephone service whatsoever.

Among some age segments, the RDD non-coverage would be substantial: 40% of young adults, ages 18–24, reside in CPOHHs, 51% of those ages 25–29, and 40% of those ages 30–34.1 After conducting an extensive pilot project in 2008, KN made the decision to move toward address-based sample (ABS) frame in response to the growing number of cell-phone- only households that are outside the RDD frame. Before conducting the ABS pilot, we also experimented with supplementing its RDD samples with cell-phone samples. However, this approach would was not cost effective—and raised a number of other operational, data quality, and liability issues (for example, calling cell phones while respondents were driving).

The key advantage of the ABS sample frame is that it allows sampling of almost all U.S.

households. An estimated 97% of households is “covered” in sampling nomenclature.

Regardless of household telephone status, those households can be reached and contacted through postal mail. Second, the KNABS pilot project revealed several additional advantages beyond expected improvement in recruiting adults from CPOHHs:

• Exclusive inclusion of the fraction of CPOHHs that have neither a landline telephone nor Internet access (approximately four to six percent of US households).

ABS involves probability-based sampling of addresses from the U.S. Postal Service’s Delivery Sequence File. Randomly sampled addresses are invited to join KnowledgePanel through a series of mailings and, in some cases, telephone follow-up calls to non-responders when a telephone number can be matched to the sampled address. Operationally, invited households have the option to join the panel by one of several ways:

• Completing and returning a paper form in a postage-paid envelope,

• Calling a toll-free hotline maintained by Knowledge Networks, or

• Going to a dedicated KN web site and completing an online recruitment form.

After initially accepting the invitation to join the panel, respondents are then “profiled” online by answering key demographic questions about themselves. This profile is maintained through the same procedures that were previously established for RDD-recruited panel members.

Respondents not having an Internet connection are provided a laptop computer and free Internet service. Respondents sampled from the ABS frame, like those sampled from the RDD frame, are 1 Blumberg SJ, Luke JV. Wireless substitution: Early release of estimates from the National Health Interview Survey, January–June 2010. National Center for Health Statistics. December 2010. Available from: www.cdc.gov/nchs/nhis.htm.

APPENDIX E1: Knowledge Networks Project Report E1-12 13 offered the same privacy terms and confidentiality protections that we have developed over the years and that have been reviewed by dozens of Institutional Review Boards.

Large-scale ABS sampling for KnowledgePanel recruitment began in April 2009. As a result, sample coverage on KnowledgePanel of CPOHHs, young adults, and non-whites has been increasing steadily since that time.

Because KnowledgePanel members have been recruited from two different sample frames, RDD and ABS, KN implemented several technical processes to merge samples sourced from these frames. KN’s approach preserves the representative structure of the overall panel for the selection of individual client study samples. An advantage of mixing ABS frame panel members in any KnowledgePanel sample is a reduction in the variance of the weights. ABS-sourced samples tend to align more closely to the overall demographic distributions in the population, and thus the associated adjustment weights are somewhat more uniform and less varied. This variance reduction efficaciously attenuates the sample’s design effect and confirms a real advantage for study samples drawn from KnowledgePanel with its dual frame construction.

Sampling and Recruitment Procedures for KnowledgePanel LatinoSM In addition to the above-documented English-based panel recruitment, in 2008 Knowledge Networks constructed KnowledgePanel LatinoSM to provide researchers with the capability to conduct representative online surveys in the U.S. Hispanic community. Prior to the advent of KnowledgPanel Latino, there did not exist in anywhere in the U.S. an online panel that represented Hispanics with and without Internet access and that reached that part of the U.S.

population able to participate in surveys only in Spanish.

The sample for KnowledgePanel Latino was originally recruited through a hybrid telephone recruitment design based on a random-digit dialing sample of U.S. Latinos and Hispanicsurnames.

It is a geographically balanced sample that covers areas that, when aggregated, encompass approximately 93% of the nation’s 45.5 million Latinos.

KnowledgePanel Latino sample Latinos residing in 70 DMAs having Latino populations. The DMA-sampling approach was dedicated to the recruitment of Spanish-Language-Dominant adults, having been categorized as “unassimilated” on the basis of frequency of viewing Spanish-language television and use of Spanish as their primary spoken language at home. The 70 DMAs are grouped into five regions (Northeast, West, Midwest, Southeast, and Southwest).

Each region is further divided into two groupings of census tracts, those that have a “highdensity”

Latino population and those remaining, which have a “low-density” Latino population.

The threshold percent for “high density” varies by region. The five regions, each divided into the two density groups, constitute 10 unique sample frames (5 x 2).

Using a geographic targeting approach, an RDD landline sample was generated to cover the high-density census tracts within each region. Due to the inaccuracy of telephone exchange coverage, there is always some spillage outside these tracts and a smaller degree of non-coverage within these tracts. About 32% of the Latino population across these five regions is covered

The remaining 68% of the Latinos in these five regions were addressed through a listed-surname sample. Listed surnames include only those households where the telephone subscriber has a surname that has been pre-identified as likely to be a Latino surname. It is important to note that excluded from this low-density listed sample frame are: (a) the mixed Latino/non-Latino households where the subscriber does not have a Latino surname and (b) all the unlisted landline Latino households. The percent of listed vs. unlisted varies at the DMA level. The use of the listed surname was intended to utilize cost-effective screening to locate Latino households in these low-density areas since the rate of finding Latino households on this list, although not 100%, is still very high.

In 2011, the above described hybrid design was replaced with national RDD samples targeting telephone exchanges that penetrate census blocks with a 50% or greater Latino population density. Households are screened in the Spanish language to recruit only those homes where Spanish is spoken at least half the time. This 100% probability-based RDD Spanish-language sample supplements the Latino households (English and Spanish) that are now recruited through KN’s general ABS recruitment sample.

Survey Administration For client surveys, samples are drawn at random from among active panel members. Depending on the study, eligibility criteria will be applied or in-field screening of the sample will be carried out. Sample sizes can range widely depending on the objectives and design of the study.

Once assigned to a survey, members receive a notification e-mail letting them know there is a new survey available for them to take. This email notification contains a link that sends them to the survey questionnaire. No login name or password is required. The field period depends on the client’s needs and can range anywhere from a few hours to several weeks.

After three days, automatic email reminders are sent to all non-responding panel members in the sample. If email reminders do not generate a sufficient response, an automated telephone reminder call can be initiated. The usual protocol is to wait at least three to four days after the email reminder before calling. To assist panel members with their survey taking, each individual has a personalized “home page” that lists all the surveys that were assigned to that member and have yet to be completed.

Knowledge Networks also operates an ongoing modest incentive program to encourage participation and create member loyalty. Members can enter special raffles or can be entered into special sweepstakes with both cash rewards and other prizes to be won.

APPENDIX E1: Knowledge Networks Project Report E1-14 15 The typical survey commitment for panel members is one survey per week or four per month with duration of 10 to 15 minutes per survey. Some client surveys exceed this time, and in the case of longer surveys, an additional incentive can be provided.

Survey Sampling from KnowledgePanel Once Panel Members are recruited and profiled, they become eligible for selection for specific client surveys. In most cases, the specific survey sample represents a simple random sample from the panel, for example, a general population survey. Customized stratified random sampling based on profile data can also be conducted as required by the study design.

The general sampling rule is to assign no more than one survey per week to members. Allowing for rare exceptions during some weeks, this limits a member’s total assignments per month to four or six surveys. In certain cases, a survey sample calls for pre-screening, that is, members are drawn from a subsample of the panel (such as females, Republicans, grocery shoppers, etc.). In such cases, care is taken to ensure that all subsequent survey samples drawn that week are selected in such a way as to result in a sample that remains representative of the panel distributions.

For this survey, the following samples were selected and invited to participate:

• Current smokers above the 200% federal poverty level aged 18 and over

• Current smokers at or below the 200% federal poverty level aged 18 and over

• Former or non-smokers above the 200% federal poverty level aged 18 and over

• Former or non-smokers at or below the 200% federal poverty level aged 18 and over

• African Americans aged 18 and over

• Predominantly Spanish speaking Hispanics aged 18 and over

• Teenagers aged 14 to 17 Sample Weighting The design for KnowledgePanel® recruitment begins as an equal probability sample with several enhancements incorporated to improve efficiency. Since any alteration in the selection process is a deviation from a pure equal probability sample design, statistical weighting adjustments are made to the data to offset known selection deviations. These adjustments are incorporated in the sample’s base weight.

There are also several sources of survey error that are an inherent part of any survey process, such as non-coverage and non-response due to panel recruitment methods and to inevitable panel attrition. We address these sources of sampling and non-sampling error by using a panel demographic post-stratification weight as an additional adjustment.

APPENDIX E1: Knowledge Networks Project Report E1-15 16 Prior to this adjustment, Spanish-speaking Latinos are separately weighted before they are merged and re-weighted with the overall panel. This ethnic group is augmented with an independent, geographically targeted, dual frame sample screened for Spanish-languagedominant households. A Spanish-language base weight incorporating selection and language usage adjustments will be described in more detail below. The overall panel demographic poststratification weight, when calculated for all panel members, proportionally adjusts for the Spanish-speaking U.S. population.

All the above weighting is done before the study sample is drawn. Once a study sample is finalized (all data collected and a final data set made), a set of study-specific post-stratification weights are constructed so that the study data can be adjusted for the study’s sample design and for survey non-response.

A description of these types of weights follows.

The Base Weight In a KnowledgePanel sample there are seven known sources of deviation from an equal probability of selection design. These are corrected in the Base Weight and are described below.

1. Under-sampling of telephone numbers unmatched to a valid mailing address An address match is attempted on all the Random Digit Dial (RDD)-generated telephone numbers in the sample after the sample has been purged of business and institutional numbers and screened for non-working numbers. The success rate for address matching is in the 60 to 70% range. Households having telephone numbers with valid addresses are sent an advance letter, notifying them that they will be contacted by phone to join KnowledgePanel. The remaining, unmatched numbers are under-sampled as a recruitment efficiency strategy. Advance letters improve recruitment success rates.

Under-sampling was suspended between July 2005 and April 2007. It was resumed in May 2007, using a sampling rate of 0.75. RDD recruitment ended in July 2009.

2. RDD selection proportional to the number of telephone landlines reaching the household As part of the field data collection operation, information is collected on the number of separate telephone landlines in each selected household. The probability of selecting a multiple-line household is down-weighted by the inverse of the number of landlines.

RDD recruitment ended in July 2009.

3. Some minor oversampling of Chicago and Los Angeles in early pilot surveys Two pilot surveys carried out in Chicago and Los Angeles when the panel was initially being built increased the relative size of the sample from these two cities. With natural attrition and growth in size, that impact is disappearing over time. It remains part of our

APPENDIX E1: Knowledge Networks Project Report E1-16 17 base adjustment weighting because of a small number of extant panel members from that initial panel cohort.

4. Early oversampling the four largest states and central region states At the time when the panel was first being built, survey demand in the four largest states (California, New York, Florida, and Texas) necessitated oversampling during January– October 2000. Similarly, the central region states were oversampled for a brief period of time. These now diminishing effects still remain in the panel membership and thus weighting adjustments are required for these geographic areas.

5. Under-sampling of households not covered by the MSN® TV service network Certain small areas of the U.S. are not serviced by MSN®, thus the MSN®TV units distributed to non-Internet households prior to January 2009 could not be used for those recruited non-Internet households. Overall, the result is a small residual under-sample in those geographic areas which requires a minor weighting adjustment for those locations.

Since January 2010, laptop computers with dial-up access are being distributed to non- Internet households thus eliminating this under-coverage component.

6. RDD oversampling of African American and Hispanic telephone exchanges As of October 2001, oversampling of telephone exchanges with a higher density of minority households (specifically, African American and Hispanic) was implemented to increase panel membership for those groups. These exchanges were oversampled at approximately twice the rate of other exchanges. This oversampling is corrected in the base weight. RDD recruitment ended in July 2009.

7. Address-based sample phone match adjustment Toward the end of 2008, Knowledge Networks began recruiting panel members by using an address-based sample (ABS) frame in addition to RDD recruitment. Once recruitment through the mail, including follow-up mailings to ABS non-respondents was completed, telephone recruitment was added. Non-responding ABS households where a landline telephone number could be matched to an address were subsequently called and telephone recruitment was initiated. This effort resulted in a slight overall disproportionate number of landline households being recruited in a given ABS sample.

A base weight adjustment is applied to return the ABS recruitment panel members to the sample’s correct national proportion of phone-match and no phone-match households.

Census blocks with high density minority communities were oversampled (Stratum 1) and the balance of the census blocks (Stratum 2) were relatively under-sampled. The definition of high density and minority community and the relative proportion between strata differed among specific ABS samples. An appropriate base weight adjustment is applied to each sample to correct for this stratified design.

The Spanish Language Base Weight In 2008, as an augmentation to KnowledgePanel, Spanish language-specific panel members were recruited through a geographically targeted dual frame sample that was screened for Spanishlanguage dominant households. Generally, these are households in which members speak Spanish and completed the recruitment interview in Spanish. Eleven geographic regions covering approximately 95% of the national Latino population was screened. Each region had both high and low density Hispanic population areas. High density areas were screened by using RDD methods, whereas low density areas were screened by using Hispanic surname listed samples.

Two adjustments are incorporated in the Spanish language base weight.

1. Selection proportional to the number of telephone landlines reaching the household As part of the field data collection operation, information was collected on the number of separate telephone landlines in each eligible (Spanish-speaking) household. A multipleline household’s selection probability is down-weighted by the inverse of its number of landlines.

2. Geographic frame balancing for RDD and listed surname samples The recruitment sample frame has a given proportional distribution across 11 regions, each consisting of both a high and low Hispanic population density area (ranging from
0.3% density to 13.9%; average = 4.6%). This adjustment factor returns the recruited households by area to their correct relative proportion across the 22 geographic density areas.

Study-Specific Post-Stratification Weights Once all the study data are collected and made final, a post-stratification process is used to adjust for any survey non-response as well as any non-coverage or under- and over-sampling resulting from the study-specific sample design. Demographic and geographic distributions for the noninstitutionalized, civilian population ages 14+ from the most recent CPS (March 2010 Supplemental) are used as benchmarks in this adjustment. The Spanish language proficiency distributions are from the most currently available Pew Hispanic Center Survey (2007). The benchmark distributions for Internet access among the U.S. population of adults are obtained

• Education (Less than High School, High School, Some College, Bachelors and higher)

• Census Region (Northeast, Midwest, South, West)

• Metropolitan Area (Yes, No)

• Internet Access (Yes, No)

• Parents of 14 to 17 years old (Yes, No)2

• Smoking and Poverty Status (Current smokers above 200% federal poverty level, Former/Non smokers above 200% federal poverty level, Current smokers at or below 200% federal poverty level, Former/Non smokers at or below 200% federal poverty level)3 For the teenage sample, KN adjusted probability of selection based on the number of children aged 14 to 17 in the household before post-stratification. The following variables are utilized for the post-stratification adjustment to the benchmarks of teens aged 14 to 17 in the U.S. to create weight2:

• Federal Poverty Level (Above 200%, At or below 200%) For the adult and teen sample combined, the following variables are utilized for the poststratification adjustment to the benchmarks of adults aged 14 and over in the U.S. to create weight3:

• Gender (Male/Female)

• Age (14-17,18–29, 30–44, 45–59, and 60+) 2 Based on the benchmarks from the KnowledgePanel® 3 3 Based on the benchmarks from the KnowledgePanel®

• Education (Less than High School, High School, Some College, Bachelors and higher)

• Census Region (Northeast, Midwest, South, West)

• Metropolitan Area (Yes, No)

• Internet Access (Yes, No)

• Parents of 14 to 17 years old (Yes, No, Teens)4

• Smoking and Poverty Status (Current smokers above 200% federal poverty level, Former/Non smokers above 200% federal poverty level, Current smokers at or below 200% federal poverty level, Former/Non smokers at or below 200% federal poverty level, Teens above 200% federal poverty level, Teens at or below 200% federal poverty level)5 Comparable distributions are calculated by using all consented cases from the field data. Since study sample sizes are typically too small to accommodate a complete cross-tabulation of all the survey variables with the benchmark variables, a raking procedure is used for the poststratification weighting adjustment. This procedure adjusts the sample data back to the selected benchmark proportions. Through an iterative convergence process, the weighted sample data are optimally fitted to the marginal distributions.

After this final post-stratification adjustment, the distribution of the calculated weights are examined to identify and, if necessary, trim outliers at the extreme upper and lower tails of the weight distribution. The post-stratified and trimmed weights are then scaled to the sum of the total sample size of all consented respondents for adults, teens, and teens and adults combined.

4 Based on the benchmarks from the KnowledgePanel® 5 5 Based on the benchmarks from the KnowledgePanel®

You are invited to be part of a KnowledgePanel® Members study. The survey focuses on health issues. It will take about 20 minutes.

You get to speak out on issues that are important to Americans, and your feedback will help us learn how to reach other people like you with important messages about health. You can skip any questions you don’t want to answer or stop anytime.

Participation is completely voluntary. You may withdraw your consent or discontinue participation at any time without penalty. As always, your identity will be unknown in all data resulting from the study. The researchers will not have access to your name or any of your identifying information. If you have questions contact Knowledge Networks at (800) 782-6899.

(SHOW IF XSMSMOKE=5,7) In appreciation of your time, you will be given 5,000 points.

S4a. If you decide to participate, the survey will follow. Would you like to participate in this survey?

This survey focuses on attitudes and behaviors of teens aged 14 through 17. We’re contacting you because our records show that there is at least one child in that age range living in your household.

The survey will take approximately 20 minutes. We would like your permission for your child to complete this survey. Your decision to allow your child to take part in this research study is completely voluntary. Your child can refuse to answer any question and can stop the survey at any time. If you decide to allow your child to take part but later change your mind, you and your child will not be contacted again or asked for further information.

As always, your child’s identity will be unknown in all data resulting from the study. The researchers will not have access to your child’s name or any identifying information. If you have questions contact Knowledge Networks at (800) 782-6899.

Your child will receive 5,000 points as an appreciation for completing the survey.

[NUMBER BOX, 0-20]

[PROMPT, TERMINATE IF 0 OR REFUSED]

S2. To be sure that we have the most current information, please let us know how many children between ages 14 through 17 live in your household for whom you are the legal guardian.

_____[NUMBOX 0-20]_____

[TERMINATE IF S2=0]

[GRID/TEXT BOX; PROMPT]

S2A. Now, please enter the first name or initial and age for [IF S2=1, INSERT “the child”; IF S2 > 1, INSERT “each of the children age 14 through 17”] below.

[TERMIANTE IF REFUSED TO ANY FIELDS]

[IF S2>1, THE RANDOMLY SELECT ONE CHILD ABOVE AND RECORD CHILD NAME, AGE, AND GENDER OF THE CHILD SELECTED]

[SP]

[IF S2>0]

S1. Do you agree to allow [INSERT CHILD NAME] to participate in this survey?

Yes ……… 1 No ……… TERMINATE TERMINATE if skip FIRST NAME or INITIALS AGE GENDER [SP]

We greatly appreciate your effort to describe your child’s background using the standard categories provided. These race categories may not fully describe your child, but they do match those used by the Census Bureau. It helps us compare our survey respondents to the U.S. population.

ChildReady. Is [INSERT CHILD NAME] ready to complete the rest of the survey now?

Yes No [DISPLAY]

[IF CHILDREADY=NO OR SKIP]

This is not a problem. When your child is available you can come back to this survey by accessing your panel member page. You will see the study with the title “Social Issues”.

APPENDIX E1: Knowledge Networks Project Report E1-24 25 Thanks so much for your help up to this point, please remember to come back to this study when your child is available.

[LOOP BACK TO THE SCREEN BEFORE CHILDREADY]

[IF CHILDREADY=1]

ChildLang. Would you like [INSERT CHILD NAME] to take the survey in English or Spanish?

English Spanish [IF ENGLISH OR SKIP, CONTINUE IN ENGLISH]

[IF SPANISH, CONTINUE IN SPANISH]

[DISPLAY]

YOUTH_ASSENT.

You are invited to be part of a group of KnowledgePanel® Members study. The survey focuses on attitudes and behaviors of young people. It will take about 20 minutes.

You get to speak out on issues that are important to young people, and your feedback will help us learn how to reach other young people like you with important information about health topics. You can skip any questions you don’t want to answer or stop anytime.

Participation is completely voluntary. You may withdraw your consent or discontinue participation at any time without penalty. As always, your identity will be unknown in all data resulting from the study. The researchers will not have access to your name or any of your identifying information. If you have questions contact Knowledge Networks at (800) 782-6899.

In appreciation of your time, you will be given 5,000 points.

S4b. If you decide to participate, the survey will follow. Would you like to participate in this survey?

For the next part of the survey you will read several statements about smoking. Please provide your opinions about each one.

[THIS SECTION OF THE SURVEY WILL REPEAT THREE TIMES. SELECT THREE RANDOM TOPIC AREAS TO SHOW PARTICIPANTS, BALANCING ACROSS CONDITIONS.]

[REPEATING AREA STARTS HERE]

[DISPLAY]

Please read the following statement about smoking. After you read the statement, you will answer a series of questions about it. Please select next when you have finished reading the statement and are ready to answer the questions.

[THIS PART OF THE SURVEY REQUIRES TWO RANDOM SELECTIONS. FIRST, RANDOMLY DETERMINE THE TOPIC ORDER FOR THE REPEATING SERIES. FOR EXAMPLE: A,E,C. WITHIN EACH TOPIC AREA, FURTHER RANDOMLY SELECT ONE OF FIVE STATEMENTS (PER TOPIC) TO SHOW (FOUR EXPERIMENTAL AND ONE CONTROL). PLEASE BALANCE DESIGN SO THAT THE SAME NUMBER OF PEOPLE ARE ASSIGNED TO EACH CONDITION (TOPIC AND STATEMENT), AND EQUALIZE THESE ASSIGNMENTS ACROSS OUR SAMPLE DESIGN. SEE ATTACHED DOCUMENT “STATEMENTS TO TEST” FOR TOPIC AREAS AND TEST STATEMENTS.]

[SHOW ONE RANDOMLY SELECTED STATEMENT. AFTER RESPONDENT SELECTS CONTINUE, SHOW QUESTIONS ON A NEW SCREEN AND DO NOT SHOW STATEMENT AGAIN.]

[PLEASE NOTE: QUESTIONS ARE LARGELY CONSISTENT FOR TOPICS A-E, BUT THERE ARE SOME DIFFERENCES WHERE NOTED. THUS, THE QUESTIONS BEING ASKED WILL VARY SLIGHTLY AS THIS SERIES IS REPEATED THREE TIMES. THE VARIATION DEPENDS ON THE TOPIC AREA A-E, BUT NOT ON THE STATEMENT SELECTED. THERE IS ALSO VARIATION BASED ON SMOKER STATUS AS DERIVED IN SECTION 1.]

[DISPLAY SELECTED STATEMENT FOR TOPIC1, TOPIC2, OR TOPIC3]

[RADIO]

New1. How confusing, if at all, would you say that this statement was for you to understand?

18. After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

a. I would believe an opposite claim.

b. I would not believe an opposite claim.

c. This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

d. Not sure DELETE NEW 2 [RADIO]

[DISPLAY SELECTED STATEMENT FOR TOPIC1, TOPIC2, OR TOPIC3]

19. After seeing this statement, if you were later to hear that it has not been proven that [IF TOPIC =A, INSERT: smoking cigarettes is bad for your health; IF TOPIC=B, INSERT: smoking and nicotine are addictive; IF TOPIC=C, INSERT: smoking “low tar,” “light,” “ultra light,”

“mild,” and “natural” cigarettes has the same health risks as smoking full-flavor cigarettes; IF TOPIC=D, INSERT: tobacco companies manipulate cigarette design; IF TOPIC=E, INSERT: secondhand smoke is harmful to other people], would you:

a. Believe that it is not proven that [IF TOPIC =A, INSERT: smoking cigarettes is bad for your health; IF TOPIC=B, INSERT: smoking and nicotine are addictive; IF TOPIC=C, INSERT: smoking “low tar,” “light,” “ultra light,” “mild,” and “natural”

c. This statement would have no impact on whether I believe that [IF TOPIC =A, INSERT: smoking cigarettes is bad for your health; IF TOPIC=B, INSERT: smoking and nicotine are addictive; IF TOPIC=C, INSERT: smoking “low tar,” “light,” “ultra light,” “mild,” and “natural” cigarettes has the same health risks as smoking fullflavor cigarettes; IF TOPIC=D, INSERT: tobacco companies manipulate cigarette design; IF TOPIC=E, INSERT: secondhand smoke is harmful to other people].

d. Not sure [[REPEATING AREA ENDS HERE; REPEAT SECTIONTHREE TIMES FOR TOPIC1, TOPIC2, AND TOPIC 3]]

Now you will see several statements, all on the same topic. These statements are designed to communicate [IF TOPIC4=A, INSERT: the dangers of smoking; IF TOPIC4=B, INSERT: the addictiveness of smoking and nicotine; IF TOPIC4=C, INSERT: the lack of any significant health benefit from smoking “low tar,” “light,” “ultra light,” “mild,” and “natural,” cigarettes; IF TOPIC4=D, INSERT: that cigarette manufacturers manipulate cigarette design and composition to ensure optimum nicotine delivery; IF TOPIC4=E, INSERT the negative health effects of exposure to secondhand smoke].

Now, looking at all five statements together, please rank the statements from 1 to 5, with 1 being the one that most clearly communicates about [IF TOPIC4=A: the dangers of smoking; IF TOPIC4=B: the addictiveness of smoking and nicotine; IF TOPIC4=C: “low tar,” “light,” “ultra light,”

“mild,” and “natural” cigarettes; IF TOPIC4=D: cigarette design; IF TOPIC4=E: secondhand smoke], and with 5 being the one that least clearly communicates about that topic. In making your determination, please consider whether you would pay attention to it and how easy it is to understand.

Question from client: On the page where they see all 5 statements together (q26) to compare them, is there any way to better distinguish them from one another (e.g., larger header breaks, darker table lines, more dramatic color changes)?

• A federal court is requiring tobacco companies to tell the truth about smoking. Here’s the truth:

• The Surgeon General has concluded:

• A United States District Court has found that:

• Here’s the truth from the U.S. Surgeon General and the National Cancer Institute:

APPENDIX E1: Knowledge Networks Project Report E1-36 37 [RADIO]

[REPEAT INTRODUCTION]

[SHOW Q27 AND Q28 ON THE SAME SCREEN]

Thinking about this introduction, please answer the following questions:

27. This introduction grabbed my attention.

a. Strongly Agree

b. Agree

c. Disagree

d. Strongly Disagree

e. Don’t know [RADIO]

28. How likely would you be to trust the statement based on that introduction?

a. Very likely

b. Likely

c. Somewhat likely

d. Not at all likely

e. Don’t know [DISPLAY]

Again, please imagine that you were to see some of the statements you’ve seen in this survey in a newspaper advertisement, on TV, online, or in a store. The statements may end with the following sentence:

[RANDOMLY SHOW ONE ATTRIBUTION FROM BULLETED LIST BELOW. BALANCE NUMBER OF RESPONDENTS WHO VIEW EACH INTRODUCTION ACROSS CONDITIONS.]

[RECORD VARIABLE AS “ENDTEXT”]

• Paid for by [Cigarette Company Name] under order of a United States District Court.

• This message is furnished by [Cigarette Company Name] pursuant to a Court Order and is taken from the 2004 Surgeon General’s Report.

• These conclusions are contained in the 1988 Surgeon General’s Report. [Cigarette Company Name] encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

• This message is furnished pursuant to a Court Order by [Cigarette Company Name].

[RADIO]

[REPEAT INTRODUCTION]

[SHOW Q29 AND Q30 ON THE SAME SCREEN]

Thinking about this sentence, how much do you agree or disagree with the following?

29. This information would make me trust the statements.

a. Strongly Agree

b. Agree

c. Disagree

d. Strongly Disagree

APPENDIX E1: Knowledge Networks Project Report E1-37 38

e. Don’t know [RADIO]

30. This information would make me question the accuracy of the statements.

a. Strongly Agree

b. Agree

c. Disagree

d. Strongly Disagree

e. Don’t know [DISPLAY]

Thank you! This concludes our study. We appreciate your time and assistance.

B-2: Philip Morris Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but this should not deter smokers who want to quit from trying to do so.

• Cigarettes and other forms of tobacco are addicting. Nicotine is the drug in tobacco that causes addiction.

These conclusions are contained in the 1988 Surgeon General’s Report. [Cigarette Manufacturer Name] encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

B-5: Interveners We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and all it takes to quit is willpower.

Here’s the truth:

• Smoking is very addictive. And it’s not easy to quit.

• We manipulated cigarettes to make them more addictive.

• When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a federal district court.

B-6: Salter>Mitchell Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell the truth about smoking.

Here’s the truth:

• The nicotine in cigarettes is highly addictive. Cigarettes can be harder to quit than heroin and cocaine.

• Nicotine changes people’s brains so they crave cigarettes the same way they want food when they’re hungry and water when they’re thirsty.

• The result: People keep buying cigarettes long after they wish they had quit.

C-2: Philip Morris There is no safe cigarette. “Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should not assume that these brands are safe or safer than full flavor brands or that smoking these brands will help you quit. If you are concerned about the health risks of smoking, you should quit.

• Smoking cigarettes with lower machine•measured yields of tar and nicotine (including those that have been labeled “low tar,” “light,” “ultra light, “mild” and “natural”) provides no clear benefit to health in comparison to smoking cigarettes with higher machine•measured yields of tar and nicotine.

This conclusion is contained in the 2004 Surgeon General’s Report. [Cigarette Manufacturer Name] encourages consumers to rely upon the conclusions of the Surgeon General in making decisions about smoking.

C-5: Interveners We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sustain our profits.

We knew that many smokers switch to low tar and light cigarettes rather than quitting because they believe low tar and lights are less harmful. They are NOT.

Here’s the truth:

• Just because lights and low•tar cigarettes feel smoother, that doesn’t mean they are any better for you. Light cigarettes can deliver the same amounts of tar and nicotine as regular cigarettes.

D-2: Philip Morris Cigarettes deliver tar and nicotine. Well known design features affect the delivery of tar and nicotine. The amount of tar and nicotine you inhale will vary, depending upon how you smoke. Generally speaking, the more intensely you smoke a cigarette, the more tar and nicotine you will inhale.

D-3: RJ Reynolds A United States District Court has found that:

• “Cigarettes are specifically designed to deliver a range of nicotine doses so that a smoker can obtain her optimal dose from virtually any cigarette on the market, regardless of that cigarette’s nicotine delivery level as measured by the FTC method.”

• “Cigarette manufacturers controlled the amount and form of nicotine delivery in commercial products by controlling the physical and chemical make•up of the tobacco blend and filler.”

This message is furnished pursuant to a Court Order by [Cigarette Manufacturer Name].

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

D-5: Interveners For decades, we denied that we controlled the level of nicotine delivered in cigarettes.

Here’s the truth:

• Cigarettes are a finely•tuned nicotine delivery device designed to addict people.

• We control nicotine delivery to create and sustain smokers’ addiction, because that’s how we keep customers coming back.

• We also add chemicals, such as ammonia, to enhance the impact of nicotine and make cigarettes taste less harsh.

• When you smoke, the nicotine actually changes the brain—that’s why quitting is so hard.

Paid for by [Cigarette Manufacturer Name] under order of a federal district court.

D-6: Salter>Mitchell A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

E-2: Philip Morris Public health officials have concluded that secondhand smoke from cigarettes causes disease, including lung cancer and heart disease, in non-smoking adults, as well as causes conditions in children such as asthma, respiratory infections, cough, wheeze, otitis media (middle ear infection) and Sudden Infant Death Syndrome.

E-3: RJ Reynolds The Surgeon General has concluded:

• Exposure to environmental tobacco smoke has been proven to cause premature death and disease in children and in adults who do not smoke. Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. The scientific evidence indicates that there is no risk•free level of exposure to second•hand smoke.

This message is furnished by [Cigarette Manufacturer Name] pursuant to a Court Order and is taken from the 2006 Surgeon General’s Report.

You should rely upon your medical provider and the Surgeon General in making decisions regarding smoking.

E-5: Interveners For decades we denied the harms of secondhand smoke.

Here’s the truth from the U.S. Surgeon General and National Cancer Institute:

• Secondhand smoke has been proven to cause lung cancer and heart attacks and kills over 38,000 Americans each year.

• There is no risk•free exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

Paid for by [Cigarette Manufacturer Name] under order of a federal district court.

E-6: Salter>Mitchell A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

Here’s the truth:

APPENDIX E1: Knowledge Networks Project Report E1-47 48

• Secondhand smoke kills 38,000 Americans every year.

• Children exposed to cigarette smoke suffer more from asthma, pneumonia, bronchitis and ear infections. Adults exposed also suffer because they inhale the same chemicals from secondhand smoke that kill and disable smokers.

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

3 For decades, we denied that smoking was dangerous. Here’s the truth:1200 Americans die every day from smoking–i 4 A federal court is requiring tobacco companies to tell the truth about cigarette smoking.

6 Cigarette smoking is addictive. The nicotine in cigarette smoke is addictive. It can be difficult to quit smoking, but t 7 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 8 We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and 9 Tobacco companies testified before Congress that nicotine isn’t addictive. Now a federal court is requiring them to tell 10 SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, And May Complicate Pregnancy.

11 There is no safe cigarette.

“Low tar,” “light,” “ultra light,” “medium,” and “mild” brands are no exception. You should 12 The following statement is made by [Cigarette Manufacturer Name] pursuant to a Court Order in United States v. [Cigar 13 We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sust 14 For years, tobacco Valid Frequency Percent Valid Percent Cumulative Percent

pursuant to a Court Order and is taken from the 2004 Surge 3 These conclusions are contained in the 1988 Surgeon General’s Report. [Cigarette Company Name] encourages consum 4 This message is furnished pursuant to a Court Order by [Cigarette Company Name].

APPENDIX E1: Knowledge Networks Project Report E1-82 83 A2_Q12 [A-2: Philip Morris] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-84 85 A3_Q11 [A-3: RJ Reynolds] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-86 87 A3_Q13c [A-3: RJ Reynolds] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-87 88 A5_Q12 [A-5: Interveners] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-88 89 A5_Q13b [A-5: Interveners] [Reading this statement makes me want to stay smokefree.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-89 90 A6_Q11 [A-6: Salter>Mitchell] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-90 91 A6_Q13a [A-6: Salter>Mitchell] [Reading this statement makes me think about quitting smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-91 92 A6_Q13c [A-6: Salter>Mitchell] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-92 93 A_control_Q12 [A - Control-2] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-94 95 B2_Q11 [B-2: Philip Morris] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-96 97 B4_Q11 [B-4: Lorillard] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-97 98 B4_Q13a [B-4: Lorillard] [Reading this statement makes me think about quitting smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-98 99 B4_Q13c [B-4: Lorillard] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-99 100 B5_Q12 [B-5: Interveners] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-100 101 B5_Q13b [B-5: Interveners] [Reading this statement makes me want to stay smokefree.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-101 102 B6_Q11 [B-6: Salter>Mitchell] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-102 103 B6_Q13a [B-6: Salter>Mitchell] [Reading this statement makes me think about quitting smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-103 104 B6_Q13c [B-6: Salter>Mitchell] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-104 105 B_control_Q12 [B - Control-2] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-106 107 C2_Q11 [C-2: Philip Morris] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-108 109 C2_Q13c [C-2: Philip Morris] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-109 110 C4_Q12 [C-4: Lorillard] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-110 111 C4_Q13b [C-4: Lorillard] [Reading this statement makes me want to stay smokefree.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-111 112 C5_Q11 [C-5: Interveners] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-112 113 C5_Q13a [C-5: Interveners] [Reading this statement makes me think about quitting smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-113 114 C5_Q13c [C-5: Interveners] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-114 115 C6_Q12 [C-6: Salter>Mitchell] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-115 116 C6_Q13c [C-6: Salter>Mitchell] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-116 117 C_control_Q12 [C - Control-2] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-118 119 D2_Q11 [D-2: Philip Morris] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-120 121 D2_Q13c [D-2: Philip Morris] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-122 123 D3_Q13c [D-3: RJ Reynolds] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-123 124 D5_Q12 [D-5: Interveners] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-124 125 D5_Q13c [D-5: Interveners] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-125 126 D6_Q12 [D-6: Salter>Mitchell] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-126 127 D6_Q13b [D-6: Salter>Mitchell] [Reading this statement makes me want to stay smokefree.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-127 128 D_control_Q11 [D - Control-1] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-129 130 E2_Q11 [E-2: Philip Morris] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-131 132 E2_Q13c [E-2: Philip Morris] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-132 133 E3_Q12 [E-3: RJ Reynolds] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-133 134 E3_Q13c [E-3: RJ Reynolds] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-134 135 E5_Q12 [E-5: Interveners] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-135 136 E5_Q13b [E-5: Interveners] [Reading this statement makes me want to stay smokefree.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-136 137 E6_Q11 [E-6: Salter>Mitchell] [Reading this statement gives me an urge for a cigarette.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-137 138 E6_Q13a [E-6: Salter>Mitchell] [Reading this statement makes me think about quitting smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-138 139 E6_Q13c [E-6: Salter>Mitchell] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-139 140 E_control_Q12 [E - Control-2] [Reading this statement makes me want a cigarette right now.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-140 141 E_control_Q13c [E - Control-5] [Reading this statement makes me want to stay a non-smoker.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-168 169 D2_Q15d [D-2: Philip Morris] [Cigarettes have been designed to make it harder for smokers to stop smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-169 170 D3_Q15d [D-3: RJ Reynolds] [Cigarettes have been designed to make it harder for smokers to stop smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-170 171 D5_Q15d [D-5: Interveners] [Cigarettes have been designed to make it harder for smokers to stop smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-171 172 D6_Q15d [D-6: Salter>Mitchell] [Cigarettes have been designed to make it harder for smokers to stop smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-172 173 D_control_Q15d [D - Control-2] [Cigarettes have been designed to make it harder for smokers to stop smoking.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-177 178 E6_Q14e [E-6: Salter>Mitchell] [Secondhand smoke is harmful to non-smokers.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-178 179 E6_Q16e [E-6: Salter>Mitchell] [Secondhand smoke causes asthma and ear infections in children.] Thinking about this statement, how much do you agree or disagree with the following?

APPENDIX E1: Knowledge Networks Project Report E1-180 181 A2_Q18 [A-2: Philip Morris] [A-2: Philip Morris] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent A3_Q18 [A-3: RJ Reynolds] [A-3: RJ Reynolds] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-181 182 A5_Q18 [A-5: Interveners] [A-5: Interveners] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent A6_Q18 [A-6: Salter>Mitchell] [A-6: Salter>Mitchell] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-182 183 A_control_Q18 [A - Control-1] [A - Control-1] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent B2_Q18 [B-2: Philip Morris] [B-2: Philip Morris] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-183 184 B4_Q18 [B-4: Lorillard] [B-4: Lorillard] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent B5_Q18 [B-5: Interveners] [B-5: Interveners] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-184 185 B6_Q18 [B-6: Salter>Mitchell] [B-6: Salter>Mitchell] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent B_control_Q18 [B - Control-1] [B - Control-1] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-185 186 C2_Q18 [C-2: Philip Morris] [C-2: Philip Morris] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent C4_Q18 [C-4: Lorillard] [C-4: Lorillard] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-186 187 C5_Q18 [C-5: Interveners] [C-5: Interveners] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent C6_Q18 [C-6: Salter>Mitchell] [C-6: Salter>Mitchell] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-187 188 C_control_Q18 [C - Control-1] [C - Control-1] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent D2_Q18 [D-2: Philip Morris] [D-2: Philip Morris] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-188 189 D3_Q18 [D-3: RJ Reynolds] [D-3: RJ Reynolds] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent D5_Q18 [D-5: Interveners] [D-5: Interveners] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-189 190 D6_Q18 [D-6: Salter>Mitchell] [D-6: Salter>Mitchell] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent D_control_Q18 [D - Control-1] [D - Control-1] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-190 191 E2_Q18 [E-2: Philip Morris] [E-2: Philip Morris] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent E3_Q18 [E-3: RJ Reynolds] [E-3: RJ Reynolds] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-191 192 E5_Q18 [E-5: Interveners] [E-5: Interveners] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent E6_Q18 [E-6: Salter>Mitchell] [E-6: Salter>Mitchell] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

APPENDIX E1: Knowledge Networks Project Report E1-192 193 E_control_Q18 [E - Control-1] [E - Control-1] After seeing this statement, if you were later to hear an opposite claim, would you believe it, not believe it, or would having seen this statement make no difference on your future beliefs?

3 This statement would have no impact on whether I would believe an opposite claim I may hear in the future.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent A2_Q19 [A-2: Philip Morris] [A-2: Philip Morris] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-193 194 A3_Q19 [A-3: RJ Reynolds] [A-3: RJ Reynolds] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent A5_Q19 [A-5: Interveners] [A-5: Interveners] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-194 195 A6_Q19 [A-6: Salter>Mitchell] [A-6: Salter>Mitchell] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent A_control_Q19 [A - Control-1] [A - Control-1] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-195 196 B2_Q19 [B-2: Philip Morris] [B-2: Philip Morris] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent B4_Q19 [B-4: Lorillard] [B-4: Lorillard] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-196 197 B5_Q19 [B-5: Interveners] [B-5: Interveners] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent B6_Q19 [B-6: Salter>Mitchell] [B-6: Salter>Mitchell] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-197 198 B_control_Q19 [B - Control-1] [B - Control-1] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent C2_Q19 [C-2: Philip Morris] [C-2: Philip Morris] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-198 199 C4_Q19 [C-4: Lorillard] [C-4: Lorillard] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent C5_Q19 [C-5: Interveners] [C-5: Interveners] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-199 200 C6_Q19 [C-6: Salter>Mitchell] [C-6: Salter>Mitchell] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent C_control_Q19 [C - Control-1] [C - Control-1] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-200 201 D2_Q19 [D-2: Philip Morris] [D-2: Philip Morris] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent D3_Q19 [D-3: RJ Reynolds] [D-3: RJ Reynolds] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-201 202 D5_Q19 [D-5: Interveners] [D-5: Interveners] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent D6_Q19 [D-6: Salter>Mitchell] [D-6: Salter>Mitchell] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-202 203 D_control_Q19 [D - Control-1] [D - Control-1] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent E2_Q19 [E-2: Philip Morris] [E-2: Philip Morris] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-203 204 E3_Q19 [E-3: RJ Reynolds] [E-3: RJ Reynolds] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent E5_Q19 [E-5: Interveners] [E-5: Interveners] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-204 205 E6_Q19 [E-6: Salter>Mitchell] [E-6: Salter>Mitchell] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

3 This statement would have no impact on whether I believe that {#Q19_insert}.

4 Not sure Total Valid Missing System Total Frequency Percent Valid Percent Cumulative Percent E_control_Q19 [E - Control-1] [E - Control-1] After seeing this statement, if you were later to hear that it has not been proven that {Q19_insert}, would you:

APPENDIX E1: Knowledge Networks Project Report E1-210 211 T4_A5_Q22 [A-5: Interveners] [This statement would be good for {educating the public about the dangers of smoking}.] Please indicate whether you agree or disagree with the following.

APPENDIX E1: Knowledge Networks Project Report E1-219 220 T4_B4_Q22 [B-4: Lorillard] [This statement would be good for {educating the public about the addictiveness of smoking and nicotine}.] Please indicate whether you agree or disagree with the following.

APPENDIX E1: Knowledge Networks Project Report E1-242 243 T4_D3_Q22 [D-3: RJ Reynolds] [This statement would be good for {educating the public about cigarette design}.] Please indicate whether you agree or disagree with the following.

APPENDIX E1: Knowledge Networks Project Report E1-251 252 T4_E2_Q22 [E-2: Philip Morris] [This statement would be good for {educating the public about secondhand smoke}.] Please indicate whether you agree or disagree with the following.

APPENDIX E1: Knowledge Networks Project Report E1-260 261 T4_E_control_Q22 [E - Control-2] [This statement would be good for {educating the public about secondhand smoke}.] Please indicate whether you agree or disagree with the following.

APPENDIX E1: Knowledge Networks Project Report E1-277 Page 1 Corrective Smoking Ads Survey December 2010
- Study Details - Note: This page may be removed when the questionnaire is sent to the client. However, it must exist in the version sent to OSD.

[THIS INITIAL QUESTION SERIES (Q1-4) IS DIFFERENT FOR ADULTS AND YOUTH. PLEASE NOTE SMOKING STATUS CLASSIFICATIONS. SEVERAL QUESTIONS LATER IN THE INSTRUMENT MAKE USE OF THESE TO SHOW/HIDE DIFFERENT QUESTIONS.]

[THIS PART OF THE SURVEY REQUIRES TWO RANDOM SELECTIONS. FIRST, RANDOMLY DETERMINE THE TOPIC ORDER FOR THE REPEATING SERIES. FOR EXAMPLE: A,E,C. WITHIN EACH TOPIC AREA, FURTHER RANDOMLY SELECT ONE OF FIVE STATEMENTS (PER TOPIC) TO SHOW (FOUR EXPERIMENTAL AND ONE CONTROL). PLEASE BALANCE DESIGN SO THAT THE SAME NUMBER OF PEOPLE ARE ASSIGNED TO EACH CONDITION (TOPIC AND STATEMENT), AND EQUALIZE THESE ASSIGNMENTS ACROSS OUR SAMPLE DESIGN. SEE ATTACHED DOCUMENT “STATEMENTS TO TEST” FOR TOPIC AREAS AND TEST STATEMENTS.]

[SHOW ONE RANDOMLY SELECTED STATEMENT. AFTER RESPONDENT SELECTS CONTINUE, SHOW QUESTIONS ON A NEW SCREEN AND DO NOT SHOW STATEMENT AGAIN.]

[PLEASE NOTE: QUESTIONS ARE LARGELY CONSISTENT FOR TOPICS A-E, BUT THERE ARE SOME DIFFERENCES WHERE NOTED. THUS, THE QUESTIONS BEING ASKED WILL VARY SLIGHTLY AS THIS SERIES IS REPEATED THREE TIMES. THE VARIATION DEPENDS ON THE TOPIC AREA A-E, BUT NOT ON THE STATEMENT SELECTED. THERE IS ALSO VARIATION BASED ON SMOKER STATUS AS DERIVED IN SECTION 1.]

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